Gender and Mental Health: Combining Theory and Practice [1st ed.] 9789811553929, 9789811553936

This book focuses on various aspects of gender and mental health. Drawing on multidisciplinary perspectives and scholars

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Table of contents :
Front Matter ....Pages i-xxxix
Front Matter ....Pages 1-1
Understanding Gender and Mental Health (Nilima Srivastava, Meenu Anand)....Pages 3-17
Gender, Depression and Emotion: Arguing for a De-colonized Psychology (Bhargavi V. Davar)....Pages 19-32
Women with Mental Illness: A Psychosocial Perspective (Saswati Chakraborti)....Pages 33-46
Gender Roles in Mental Health: A Stigmatized Perspective (M. S. Bhatia, Aparna Goyal)....Pages 47-62
Understanding and Locating Mental Health in a Cross-Cultural Context: Indigenous Community Perspectives (Malathi Adusumalli)....Pages 63-76
Front Matter ....Pages 77-77
Mental Health Aspects of the ‘#MeToo Movement’: Challenges and Opportunities (R. Srinivasa Murthy)....Pages 79-96
The Intersectionality of Gender, Disability and Mental Health (Abhishek Thakur)....Pages 97-108
Gender and Schizophrenia: Are Differences Biological or Social? (Ananya Mahapatra, Smita N. Deshpande)....Pages 109-127
Urban Women and Mental Health Concerns in India (Vibhuti Patel)....Pages 129-142
Female Criminality, Mental Health & the Law (Saumya Uma)....Pages 143-156
Front Matter ....Pages 157-157
Psychosocial Rehabilitation—The Past, Current Approaches and Future Perspectives (Roy Abraham Kallivayalil, Sheena Varughese)....Pages 159-172
Homelessness and Women Living with Mental Health Issues: Lessons from the Banyan’s Experience in Chennai, Tamil Nadu (Lakshmi Narasimhan, K. V. Kishore Kumar, Barbara Regeer, Vandana Gopikumar)....Pages 173-191
Tarasha’s Experience of Working with Women Living with Mental Illness: ‘Melee tar aamchi, Jagli tar tumchi’(‘if she dies she is ours, if she lives, she is yours’) (Shubhada Maitra, Ashwini Survase)....Pages 193-205
Gender Differentials in the Presentation of Symptoms, Assessment, Diagnosis and Treatment of Mentally Ill Prisoners (Mark David Chong, Amy Forbes, Abraham P. Francis, Jamie Fellows)....Pages 207-221
Gender and Community Mental Health: Experiences of Mehac Foundation—A Community-Based Mental Health Service in Kerala, South India (Anupama V. Prabhu, Anu Sonia Vincent, Uma Parameswaran, Chitra Venkateswaran)....Pages 223-235
Practising Strength-Based Approach with Women Survivors of Domestic Violence (Gunjan Chandhok, Meenu Anand)....Pages 237-251
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Meenu Anand   Editor

Gender and Mental Health Combining Theory and Practice

Gender and Mental Health

Meenu Anand Editor

Gender and Mental Health Combining Theory and Practice

123

Editor Meenu Anand Department of Social Work University of Delhi New Delhi, Delhi, India

ISBN 978-981-15-5392-9 ISBN 978-981-15-5393-6 https://doi.org/10.1007/978-981-15-5393-6

(eBook)

© Springer Nature Singapore Pte Ltd. 2020 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd. The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore

This book is dedicated to my father and my late mother who gave me the best and the happiest childhood.

Acknowledgements

The subject of gender has always intrigued me, as a woman and as a feminist scholar. Over the years, during the course of my research and teaching, I developed a passion for exploring gender, its many contours and subthemes. As my life evolved through varied phases, those of happiness and elation, challenges and turmoil, I steadily began to question the very notion of normality, often deeply embedded within the realm of mental health, in academic discourses as well as in societal practices. The inception of this book stemmed from a strong desire to put together an integration of schemas on mental health from an eclectic standpoint. Being a social work educator and a scholar of gender studies, I strongly believe in praxis between theory and practice. Hence, no effort of theorizing a concept can be complete (for me), without the amalgamation of field-based narratives. This book is a humble attempt to bring together the models and approaches on mental health by social work professionals, medical practitioners and academicians along with voices and chronicles from significant grass-roots practitioners/projects. I would like to thank a number of people who have been instrumental in both the genesis and production of this book. I would like to begin by thanking Prof. Werner Menski who put me in contact with Ms. Satvinder Kaur at Springer Nature. Without this first milestone, this volume would surely not have been possible. I also thank Prof. Archana Dassi for her eternal inspiration and faith in me that continues to inspire me to undertake all my professional assignments with perfection. I humbly thank Dr. Malathi Adusumalli and Prof. Nilima Srivastava for assiduously bearing with my never-ending cathartic narrations about the progress of manuscript. I sincerely thank Prof. Malashri Lal who has always encouraged me to aspire for ‘quality writing and publications’ in order to experience the true joy of taking one’s work forward. I also would like to express my humble gratitude to Ms. Satvinder Kaur at Springer Nature for her belief and confidence in my work, unequivocal warmth as well as professionalism demonstrated by her with utmost conviction and cooperation. With great humility, I would also like to sincerely thank each and every contributor of this book who trusted me immensely with this

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colossal task, sharing their unique experiences and phenomenal works, despite many of them having never met me. A special thanks to Prof. R. Srinivasa Murthy and Dr. Bhargavi V. Davar for having created a voluminous body of scholarly work in the area of mental health with so much passion and commitment which indeed has been a great source of encouragement and motivation for me. On a more personal note, I am forever thankful to my son Tanish, who has been my constant companion and a witness to my arduous journey of managing various professional and personal responsibilities. He has been my sole companion throughout the years while I burnt the midnight oil during the course of this journey, especially after having gruelling days at the university. I also wish to thank my husband Jitender for partnering and bearing with me, my mood swings, and providing unconditional and steadfast support like a loyal friend. My preoccupations certainly affected our quality time together, but he always staunchly loved me and respected my need to create my own space and carve my niche. I am equally indebted to Indu Bhabhi and Preet for cheering me and loving me tenderly whenever I was battling through bouts of loneliness. It was due to our awesome and ‘foursome’ camaraderie (along with Tanish) that I sailed through difficult phases by laughing out aloud amidst relishing splendid delicacies. I would also like to thank Gunjan who helped me with technical assistance and all those who provided me immense moral strength. I may have mentioned only a few names, and there have been many more persons who have impacted me, blessed me and helped me inaudibly during the course of this journey. Last but not least, I pray and hope to do justice to all my contributors and the potential readers of this book by presenting a volume which is compatible to suit the unique learning requirements of students, research scholars, academicians as well as field practitioners and enable them in their diverse works. 29th June 2020

Meenu Anand

Introduction

Mental health is gendered. The association between gender and mental health therefore has become an intersecting and prominent topic not only within the domain of sociology but also in the fields of psychology, social work, epidemiology, psychiatry and public health (Chien-Juh Gu 2006). The discourse on gender and mental health has become an integral part of the contemporary debates. According to WHO, gender refers to the range of socially constructed roles and characteristics of women and men, and sex refers to biological differences (WHO 2011; Muehlenhard and Peterson 2011). Gender and mental health have emerged as an important traversing treatise in relation to the contemporary sociocultural ethos in Indian society, its dynamics of power and politics. As a critical determinant of mental health, gender has received significant attention with respect to promotion and protection of mental health and fostering resilience to stress and adversity. Understood as varying sets or relations, norms and identities related to ideas of what constitute femininity and masculinity or transgendered identities, respectively, gender determines the differential power and control gendered individuals have over the socio-economic determinants of their mental health and lives, their social position, status and treatment in society and their susceptibility and exposure to specific mental health risks. A gendered approach to mental health implies distinguishing between biological and social factors while exploring their interactions and being sensitive to how gender inequality affects health outcomes. Few would disagree that sex is of relevance in understanding and treating mental disorders, but there seems to be less consensus on the extent to which researchers should consider sex and gender in study design, analysis and interpretation. The Institute of Medicine defines sex as ‘the classification of living things, generally as male or female according to their reproductive organs and functions assigned by chromosomal complement’ (Wizemann and Pardue 2001). Gender is defined as ‘a person’s self-representation as male or female, or how that person is responded to by social institutions based on the individual’s gender presentation. Gender is shaped by environment and experience’. These definitions have been criticized, particularly for treating sex and gender as dichotomous variables (whereas many ix

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of the sex-related and gender-related differences in function and disease are more usefully conceptualized as continuous variables) and focusing on the individual (which neglects the multidimensional relational nature of gender). Differences in the epidemiology of mental disorders in men and women are well established and are often conceptualized as being due to sex (i.e. biological) differences; the increased risk of psychosis in the post-partum period is a classic example. Sex differences in both response and adverse reactions to psychotropic medication have been identified (Howard et al. 2017).

The Notion of Normality I also wish to dwell upon the very notion of normality which in itself is a very complex as well as a contested term in the field of mental health. In fact, the concept of mental health seems to be a more complex concept than mental illness. Zachrisson (2019) questions ‘what do we mean by mental health, and what is the relation between mental health and normality?’ The medical definition of health has been the ‘absence of illness’. It has been criticized as too narrow and too somatic. In 1948, the World Health Organization (WHO) gave an alternative definition of health: a state of perfect somatic, mental and social well-being, not only the absence of illness or handicaps. The objections have been that this conception is difficult to delimit and that it denotes an unattainable ideal, not a normal state. The sociocultural notions of health denote the significant cultural variations as well as subjective understandings of the term. However, most judges agree that mental health and mental illness are not mutually exclusive. That implies that the mere absence of mental illness does not necessarily mean good or sound mental health. One way to conceptualize mental health may be to see how a person handles his/her everyday life. Thus, operationalizing the very concept of mental health is in itself a challenge. As Zachrisson (2019) argues Who of us has not felt anxiety or a hint of panic; who has not asked himself: did I lock the door and turn off the stove before I left home? Who has not had moments of confusion and loss of sense of reality or of identity feeling? Such moments are not signs of mental illness. They become illness, if they take on a dominating place in mental life. When the thoughts of the stove or the door does not leave us, but become obsessions or compulsions. Who has not felt insecure and wished to withdraw from an exciting challenge; or, the other way around, submitted to a wish to stand in the centre of peoples’ attention, without having a contribution to give? We talk of illness only when these reactions take on a dominating role, and call it narcissism—a state that in moderate form is universal (p. 2).

Jaramillo and Restrepo-Ochoa (2015) reiterate the notion of normality often understood as a criterion of demarcation between what is considered ‘healthy’ or ‘sick’, ‘adapted’ or ‘maladjusted’, and ‘welfare’ or ‘discomfort’ as a problematic situation. According to them, the notion of normality is multivalent and relative, product of the socio-historical context in which it is conceptualized, and is anchored in the interests of different groups of power (scientific, political and economic).

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The normality and abnormality debate, largely governed by the diagnostic criteria of ICD and DSM, tends to create compartmentalizations and hierarchies within the human society. The origin of the ‘other’ creates categories where people who do not fit in can be placed away from the mainstream. This may lead to prejudice and discrimination and the physical separation of people to the margins of that society. Sibley (1995) traces the physical marginalization of people in what he calls the ‘geographies of exclusion’. Part of the process of exclusion is where the ‘bad’, the ‘mad’ and the ‘imperfect’ are deemed to be ‘other’ and, often in stereotyped form, are disregarded or rejected. Being the ‘other’ in mental health terms means being on the ‘them’ side of the normality/abnormality boundary. What does it mean to be regarded as abnormal? Indeed, what is the nature of mental distress? What does it mean to have mental health problems? It all depends on where the boundaries are drawn and by whom. A boundary may often be drawn, for example, in a way that differentiates mental distress from ideas of what constitutes mental health and well-being. A person experiencing mental distress is, therefore, at least temporarily on the other side of the divide from those who are ‘normal’ or ‘sane’. Boundaries divide and define, but do they help to explain (Open Learn University 2016)? To set the tone correct, if ‘mental disorder’ means any disability or disorder of mind, this implies that there is some sort of mental ‘order’, an internal state where there are calm and coherence. The boundary between mental health and mental disorder is therefore concerned with the controversial idea of normality and what society regards as normal (Coppock and Hopton 2000). Keyes (2002) has described the mentally healthy as ‘flourishing’ and also introduced a new concept—‘languishing’. We often indulge in the importance of flourishing and pay attention to the problems associated with languishing, debate about what ‘flourishing’ and ‘languishing’ entail. However, I always wonder about the very two ends of the dual continuum model. I often find my own self, and so many others, constantly jostling and moving along the dual continuum, back and forth, stopping and (re)starting as our lives change turns, flourishing sometimes and also languishing at others. I myself have found myself struggling and hanging ‘in between’ many a time in my life. I feel that a more inclusive way of thinking about mental distress would be to avoid the fixed boundary between ‘them’ and ‘us’, and allowing everyone to move between points as circumstances change and episodes of distress come and go. Furthermore, I strongly feel that the normal–disordered discrimination needs to be challenged today as we are constantly dabbling with the upcoming thrusts on community mental health or rehabilitation of persons from a strength-based perspective. However, the reality is a far cry from these. The gender-based differentials create double whammy for women which implies hegemonic boundaries and further subjugation. Women with mental illness therefore are not only subjected to discrimination owing to them being ‘the inferior sex’ but also because they are the ‘other’ on the continuum of normality–abnormality.

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Gender Differentials in Mental Illness The boundaries between the other and the rest become more distinct when it comes to a gendered analysis. Women are exposed to a wide range of specific risk factors that can increase their risk of poor mental health (Astbury 2001; WHO 2012). Men and women experience different varieties of mental health problems. According to WHO, depression, anxiety and somatic complaints are more common for women. Unipolar depression, predicted to be the second leading cause of global disability burden by 2020 (Murray and Lopez 1996), is twice as common in women. Women are about twice as likely as men to develop depression during their lifetime (WHO 2013; Geo et al. 2019; Weissman and Olfson 1995; Desai and Jann 1999; Aneshensel 1992; Caldwell et al. 1987; Dohrenwend and Dohrenwend 1974; Gove 1972, 1987; Mirowsky and Ross 1986; Rosenfield 1989). Women also predominate in the disability associated with mental illness which falls most heavily on those who experience three or more co-morbid disorders. In contrast, while women exceed men in internalizing disorders such as depression and anxiety, men exhibit more externalizing disorders such as substance abuse and antisocial behaviour, which indeed become problematic for others. Research on gender and mental health suggests that conceptions of masculinity and femininity affect major risk factors for internalizing and externalizing problems, including the stressors men and women are exposed to, the coping strategies they use, the social relationships they engage in, and the personal resources and vulnerabilities they develop (Rosenfield 2012). Feminism has consistently rejected traditional causal explanations of women’s disorder derived from allegedly natural biological predispositions, pointing instead to the effects of women’s oppressive socialization and to the consequences of devaluing women’s characteristics and abilities (Bluhm 2011). Similarly, it has emphasized the embodiment, and relationality, of the self (Bluhm et al. 2012). Furthermore, much of it influenced by social theory and phenomenological approaches focuses on the intersection of gender with marginality, invisibility, non-normativity and oppression in lived experience (Nissim-Sabat 2013; Zeiler and Folkmarson Käll 2014 as cited in Stanford Encyclopaedia of Philosophy (2019)). At the home front, the National Mental Health Survey of India by NIMHANS (2016) too echoes the prevalence of significant gender differentials with regard to different mental disorders. The overall prevalence of mental morbidity has been found to be higher among males (13.9%) than among females (7.5%). While there is a male predominance in alcohol use disorders (9.1% vs. 0.5%) and in bipolar affective disorder (BPAD) (0.6% vs. 0.4%), specific mental disorders like mood disorders, neurotic disorders, phobic anxiety disorders, agoraphobia, generalized anxiety disorders and obsessive compulsive disorders were higher in females. Furthermore, it is significant to add that neurosis and stress-related disorders (that affected 3.5% of the population) were reported to be nearly twice higher among females as compared to males.

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Kuehner (2016) summarizes evidence regarding the epidemiology on gender differences in prevalence, incidence and course of depression, and factors possibly explaining the gender gap. Gender-related subtypes of depression are suggested to exist, of which the developmental subtype has the strongest potential to contribute to the gender gap (Kuehner 2016). Sophie and Graham (2017) present the evidence from a variety of fields that suggests that sex hormones, particularly oestradiol and progesterone, play a significant part in generation of these sex differences. They report on the effects of sex hormones on biological, behavioural and cognitive pathways, to propose broad mechanisms by which oestradiol and progesterone influence sex differences in anxiety disorders. Research by Rosenfield and Mouzon (2013) on gender and mental health suggests that gender conceptions and practices push males and females to different forms of psychopathology by increasing multiple risk factors for internalizing and externalizing problems. The amount of these risk factors makes gender differences seem socially overdetermined—that is, resulting from more causes than are necessary to produce the outcome. Men and women in different races and classes are predisposed to varying problems through the stressors they experience, the coping strategies they use, the social relationships they engage in, and the personal resources and vulnerabilities they possess. These differences also seem overdetermined insofar as the conceptions of gender underlying these risk factors are conveyed through socialization and major social institutions including schools, families and workplaces.

Sociocultural Determinants The impact of sociocultural determinants in gender-specific mental health has been a significant research topic. Not only are women exposed to a wide range of specific risk factors making them more vulnerable to mental illness, but they are also at higher risk of developing co-morbidities when these risk factors occur together (Patel 2005). Gender norms, understood as the sets of rules for what is appropriate masculine and feminine behaviour in a given cultural context, play a predominant role with respect to a sociocultural understanding with respect to gender and mental health. Since gender norms make up a sex role, a set of expectations about how someone labelled a man or someone labelled a woman should behave; feminization and masculinization take place through overt and covert means during the course of socialization, thereby becoming an internalized part of the way one engrains one’s gender identity (Anand 2019; Ryle 2015). Davar (1999) examines research on women’s mental health and synthesizes a bio-psychosocial model takes into account complex contextual factors, especially psychosocial causes. The socially constructed differences between women and men in roles and responsibilities, status and power interact with biological differences to contribute to differences in mental health problems experienced, help-seeking behaviour and the responses of the health sector (Babacan 2014).

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A strong inverse relationship exists between social position and physical and mental health outcomes. The key gender influences for women include women unduly bearing the burden of poverty, and this influences their likelihood of suffering depression; women are much more likely than men to experience violence, particularly sexual abuse and partner violence; women are more likely to work in jobs that are unstable and of low status, and carry the burden of carrying, particularly unpaid role of carer (Babaca 2014, pp. 235). The prevalence of co-morbidity increases the severity of mental illness and increased disability (Astbury 2001). Hill and Needham (2013) examine three propositions that are widely (but not universally) accepted in the gender and mental health literature. First, women and men have similar or equal rates of overall psychopathology. Second, affective disorders like anxiety and depression, which are more common among women, and behavioural disorders like substance abuse and antisocial personality, which are more common among men, are functionally equivalent indicators of misery. Finally, women are more likely to respond to stressful conditions with affective disorders, while men are more likely to respond to stressful conditions with behavioural disorders. However, their propositions received little empirical support. Ogundare (2019) highlights the role of culture in the conceptualization of mental illness and the phenomenology of mental illness across cultures. Conceptions of gender and gendered practices generally include the division of labour, the power differences between men and women, and the character traits associated with males and females. Though the scenario has been changing, men still primarily retain the primary responsibility for the economic support of the family, and women are still responsible for caretaking and domestic work, regardless of whether they are employed (Rosenfield and Smith 2009). The dominant societal form of femininity —which Connell calls emphasized femininity—stresses personal traits of submissiveness, nurturance and emotional sensitivity as ideals (Connell 1995). In contrast, dominant conceptions of masculinity—termed hegemonic masculinity—associate men with assertiveness, competitiveness and independence, traits needed for success in the labour market (Connell 1995; De Coster and Heimer 2006; Hagan 1991; Heimer 1995; Heimer and De Coster 1999; Schippers 2007; Simon 2002). Women are nearly twice as likely as men to suffer from mental illness, while men suffered from more mental health problems than women when dealing with situations of high wealth inequality (Shoukai 2018). Rosenfield and Mouzon (2013) further argue that women face more recent life events than men, and consistent with their greater responsibilities for caretaking and maintaining social ties, they suffer from more stressors involving significant others such as family events and the death of friends or relatives. In contrast to women, men endure more traumatic or adverse events over the course of their lives, e.g. indulgence in violence, substance abuse, etc. Combining these studies, women’s excess of internalizing problems partly results from the time pressure of household tasks and the overload of job and family demands. These patterns are consistent with role theory, which postulates that men’s and women’s mental health problems are derived from destructive aspects of their gender roles (Meyer et al. 2008).

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The significance of sociocultural differentials is reiterated by American Psychiatric Association (2017) that identifies disparities between women and men in regard to risk, prevalence, presentation, course and treatment of mental disorders on three accounts. First, it delineates that women disproportionately experience various risk factors for common mental disorders than men. These include violence, less earnings, poverty and role as caregivers among women as compared to men. Second, APA points out the gendered differences in seeking/receiving mental health services that include women being prescribed psychotropic drugs, seeking help from medical practitioner rather than a specialist and likelihood of being diagnosed for depression by their physicians. Third, APA lists various economic barriers, lack of awareness about mental health issues, treatment options, available services, prevalence of stigma associated with mental illness in addition to the lack of time/related support and lack of appropriate intervention strategies as key barriers to mental health treatment for women. Rosenfield and Mouzon (2013) further argue that women suffer more than men from internalizing disorders, which turn problematic feelings against the self in depression and anxiety. This difference means that women endure attributions of self-blame and self-reproach more often than men. Women struggle with a greater sense of loss, hopelessness and feelings of helplessness to improve their conditions. They also live with more fears in the forms of phobias, panic attacks and free-floating anxiety states. In contrast, men predominate in externalizing disorders and more likely to have enduring personality traits that are aggressive and antisocial in character, with related problems in forming close, enduring relationships. Gender differentials in coping mechanisms are highlighted by Ashfield (2014) who found that: Women tend to ruminate and are verbally emotionally expressive; they employ a ruminative and expressive style of coping—consistent with their sex-specific biology, cultural conditioning, and the kind of roles they perform. Men tend to suppress, are less concerned with relationships, and are generally verbal and emotional economists; they employ a more suppressive instrumental style of coping, which is likewise consistent with their sex-specific biology, cultural conditioning, and the roles they must perform. (p. 223) (as cited by Francis and Elias, 2017, p. 147).

The subject of gender differentials becomes even more relevant in the Indian mental health scenario where gross violation of women’s human rights takes place. There is a need for the state to take multipronged steps to reduce gender discrimination, act on the risk factors and promote the protective factors for enabling mental health and well-being with thrust on girls and women. There is a need for in-depth research and relevant literature in the field of gender and mental health that is backed by lessons and evidence from the field.

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What This Book Offers? This book brings together a range of scholarly as well as experiential reflections on the subject of gender and mental health. It aims to draw attention to the urgent need for amalgamation of academic as well as grass-roots realities on the theme. It seeks to explore and document the inclusion of practice-based interventions, which is actually the ‘need of the hour’. It summarizes the complex intertwining of illness and culture and attempts to combine theoretical discourses along with the success stories as well as challenges from the field. This book is divided into three parts. Part I ‘Conceptual Underpinnings for Gender and Mental Health’ brings together a theoretical understanding on gender and mental health and lays a backdrop to understand the intricacies surrounding the theme. It entails the background and multifaceted theoretical frameworks for gender and mental health. Nilima Srivastava and myself present the Introductory Framework to discuss why gender matters in mental health and explain the relationship between gender and health-seeking behaviours. Our chapter “Understanding Gender and Mental Health” attempts to present the diverse approaches related to mental health while thrusting on the significant sociocultural determinants including differential socialization as well as mental illness among women and men. The chapter seeks to interlink the issues of mental health with an attempt to probe a deeper understanding of micro-level issues within the overall context of the perpetuating nature of inequities from a gender lens. Bhargavi V. Davar in her chapter “Gender, Depression and Emotion: Arguing for a De-colonized Psychology” examines the colonial assumptions about women, their expressed emotions and ‘disorders’ of the emotions. She questions from the gender/culture perspective the colonial assumptions that (i) emotion is (located) within the individual and (ii) emotion is mental. She argues for the social and the embodied aspects of emotions reiterating that emotion is in the body and is expressed through the body. She also thrusts that emotion is always in relation to the other and often constructed with the other. Examining a few folk stories, and historically revered myths, including the Neeli myth from south India; the Kannagi story; and the story of Rudali, Davar illustrates how women’s emotions are embodied expressions of distress. She further claims that their object reference is to the other, often within contexts of patriarchal silencing and an extant milieu of violence. Saswati Chakraborti in her chapter “Women with Mental Illness: A Psychosocial Perspective” builds upon the gendered understanding of mental illness and argues how women’s mental health is intrinsically linked with the larger multifaceted social, political and economic issues prevalent across the sociocultural milieu. Citing several factors affecting mental and emotional well-being of women, she presents field-based evidence to claim how women face the gender disadvantage and are more predisposed to mental illness as against their male counterparts. The prevalence rates for psychological disorders are examined by M. S. Bhatia and Aparna Goyal in “Gender Roles in Mental Health: A Stigmatized Perspective”.

Introduction

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They base their arguments on the bio-psychosocial model of health and present a gender perspective on mental illnesses including premenstrual dysphoric disorder, post-partum psychiatric disorders, perimenopausal and menopausal disorders. As medical practitioners, they also examine the role of oestrogen in mental health while presenting the key gender-specific risk factors from a psychosocial lens and make significant recommendations towards prevention of mental disorders among women. Cross-cultural perspective and its relevance in the realm of mental health are highlighted by Malathi Adusumalli in “Understanding and Locating Mental Health in a Cross-Cultural Context: Indigenous Community Perspectives”. She explores with reference to ideas related to health and well-being from two indigenous communities—Chenchus and Jad Bhotiyas from two states, Telangana and Uttarakhand, respectively. She traverses the various articulations on health and illness, through the various ‘acts’, which are culture-bound and highlight how the ‘natural context’ is quite closely enmeshed with the belief systems and the ‘performative acts’ for health and well-being, which are gendered. She highlights the need to understand the varied notions of mental health, going beyond the notions of ‘defined categories’, including even the concept of mental health. Part II of this book ‘Mental Health Scenario in India: A Gendered Lens’ seeks to examine the contemporary scenario of mental health in the country from a gender perspective. The first paper in this part is by R. Srinivasa Murthy who divulges into the “Mental Health Aspects of the ‘#MeToo Movement’: Challenges and Opportunities”. Citing recent evidences of atrocities on women and gender discrimination prevalent in society at large, he addresses various aspects of the mental health including the recognition of the gender inequalities as vital to bring about changes, integration of mental health knowledge in recognition of the importance of equality, social connectedness, the lifelong impact of adversities like child trauma, living in conflict situations, value of family life and impact of urbanization. He also presents the importance of understanding the mental health impact of changes at the level of individuals, families, community, state, international levels as part of the change process and the need for systematic engagement of the society at many levels, to prevent or protect women against similar situations. Significant interlinkage among the diverse yet interconnected themes of “The Intersectionality of Gender, Disability and Mental Health” is examined by Abhishek Thakur. Demonstrating a link between emotional challenges and psychological struggles involved in living with impairments, he presents how various psychosocial challenges may create risk factors as well as vulnerabilities, all of which can contribute to experiences of mental distress for disabled women in their lives. Taking the idea forward, the next chapter is by two medical practitioners, Smita N. Deshpande and Ananya Mahapatra, who review the role of gender in influencing the onset, clinical symptoms, course and outcome of schizophrenia. They examine the gender standpoint in the social consequences of the illness in terms of the degree of disability, quality of life, stigma, discrimination and social outcomes. Recognizing the eclectic approach in treatment and rehabilitation, they

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too make recommendations and also signify the role of social workers in facilitating gender- and culture-sensitive interventions to improve treatment outcome in both male and female persons with schizophrenia. Vibhuti Patel in her chapter “Urban Women and Mental Health Concerns in India” deliberates on the worsening socio-economic and political situation in India that has enhanced the rates of common mental disorders and minor psychiatric morbidity. She also presents mental issues of adolescent girls, substance abusers, HIV/AIDS-affected persons and among women in the reproductive age group, post-menopausal women, women in mental health institutions, etc. Patel also suggests holistic strategies involving the civil society and the state to provide greater opportunities to women across all age groups for self-actualization to enable them to attain high levels of mental health. Last but indeed the most significant part of the section is the legal standpoint with respect to the gendered aspects of mental health as explored by Saumya Uma in “Female Criminality, Mental Health & the Law”. Uma dwells with a particular focus on female criminality and criminal law’s treatment of women accused of heinous offences. Her chapter undertakes the analysis primarily through a critical examination of judgements delivered by the High Courts and the Supreme Court of India in addition to laying out and analysing the contours of law and state responsibility vis-à-vis women’s mental health. Drawing upon a combination of medical research, theories and analysis in the field of psychology and jurisprudence around the world, analysed through a feminist perspective, she critiques recent judgements of the higher judiciary in India on both the issues. While the attempt of Indian courts to infuse a gender perspective into the criminal law defences is a positive step, the paper advocates caution, to avoid gender stereotyping of accused women, and calls for a more active conversation between relevant actors in the fields of criminal law, mental health, forensic sciences and gender studies. The third and final part ‘Gendering Mental Health: Field Narratives’ echoes voices from the field, as the most critical element for making feminist interventions in the field of mental health. It focuses on presenting and embodying narration of field experiences, the success stories as well as the challenges with thrust on praxis between theoretical understandings and grass-roots realities. The first paper in this part is by Roy Abraham Kallivayalil and Sheena Varughese as they set the tone through unveiling the concept of psychosocial rehabilitation (PSR). Kallivayalil and Varughese in their chapter “Psychosocial Rehabilitation—The Past, Current Approaches and Future Perspectives” as an essential component of management of persons with chronic mental illness along with pharmacological management. They argue about the twofold goals of psychiatric rehabilitation to help disabled individuals to develop the emotional, social and intellectual skills needed to live, learn and work in the community and develop environmental resources to reduce potential stressors. They cite their Kerala experience as a model suitable for lowand middle-income (LAMI) countries to develop innovate strategies to meet the challenges of mental illness. No piece on the success of interventions in the field of mental health can be complete without the mention of The Banyan, one of the most prominent

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organizations working in the field of mental health in India. Lakshmi Narasimhan, K. V. Kishore Kumar, Barbara Regeer and Vandana Gopikumar in their chapter “Homelessness and Women Living with Mental Health Issues: Lessons from the Banyan’s Experience in Chennai, Tamil Nadu” describe their experiences in developing a continuum of care for homeless people with mental illness. Their contribution examines the Emergency Care and Recovery Centre which offers crisis intervention to reintegration services for homeless women with mental illness and also frames within the narrative of this experience, implications for mental health policy and practice for an extremely marginalized population. In particular, they dwell on the prospects for issues of long-term care and intersectoral service integration between health and social welfare for the homeless population in the light of recent developments in progressive disability and mental health legislation in India. Another enormously significant effort in India towards rehabilitation of women recovering from mental illness is narrated by Shubhada Maitra and Ashwini Survase in their chapter “Tarasha’s Experience of Working with Women Living with Mental Illness: ‘Melee tar aamchi, Jagli tar tumchi’ (‘if she dies she is ours, if she lives, she is yours’)”. Citing real-life illustrations from their field action project, Tarasha, initiated by the Centre for Health and Mental Health, School of Social Work, Tata Institute of Social Sciences, they discuss Tarasha’s experience of working with women living with mental illness. While tracing Tarasha’s conceptualization and history, the authors outline Tarasha’s recovery and reintegration model drawing on women’s experiences who are currently ‘occupying’ mainstream living and livelihood spaces. An interesting unification of gender, criminality and mental health is presented by Mark David Chong, Amy Forbes, Abraham P. Francis and Jamie Fellows in their chapter “Gender Differentials in the Presentation of Symptoms, Assessment, Diagnosis and Treatment of Mentally Ill Prisoners.” They explore how the gender of a prisoner influences the way in which a mentally ill inmate presents their symptoms (and seeks medical assistance), as well as how they are thereafter assessed, diagnosed and treated by prison health services. They also hope that penal administrators and correctional health professionals in India will be made more aware of, or sensitive to, these variances and that the subsequent assessment, diagnosis and treatment of such prisoners will be more gender-responsive so as to maximize the prospect of successful rehabilitation. Experiential learnings from the grass roots are also presented by Anupama V. Prabhu, Anu Sonia Vincent, Uma Parameswaran and Chitra Venkateswaran from the Mehac Foundation. “Gender and Community Mental Health: Experiences of Mehac Foundation—A Community-Based Mental Health Service in Kerala, South India” outlines the experiences by the authors in dealing with mental health and illness, indicating some important developments and components of the model, with a special focus on gender. Sharing the community-based services run by Mehac Foundation, the authors focus on the importance of empowering families and providing continuous support to them enable home-based care. Last but not least, Gunjan Chandhok and myself thrust upon the importance of strength-based approach for addressing the vital concerns related to domestic

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violence in our paper “Practising Strength-Based Approach with Women Survivors of Domestic Violence”. We affirm that self-determination, self-esteem and hope among the survivors of domestic violence can be inculcated and visualized as the potential key to address the imperative mental health issues. Our chapter also suggests gender-sensitive interventions in congruence with the human rights approach. This book is unique in what it hopes to achieve: a gestalt in its unique consolidation of theoretical underpinnings on mental health from a gender lens backed by voices from the field. It is intended as a critical confederacy of theoretical base on gender and mental health depicting the contemporary scenario as well as experiential insights from the field. It will be useful to students from a number of disciplinary backgrounds interested in either gender and/or mental health—students of social work, sociology, social policy, women/gender studies, social psychiatry and psychology. It will also be suitable as reference material for professionals who encounter women and men with mental health challenges—social workers, nurses, doctors, psychologists, lawyers, etc. I also hope that this book will be useful to anyone who is battling with the personal experience of having a mental disorder or having a member of their family with one. I strongly feel that this book will be useful for postgraduate students, research scholars as well as faculty in the field of gender studies, mental health as well as social work and sociology. Meenu Anand

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Davar, B. V. (1999). Rethinking gender and mental health: A feminist agenda. Sage. De Coster, S., & Heimer, K. (2006). Crime at the intersections: Race, class, gender, and violent offending. In R. D. Peterson, L. J. Krivo, & J. Hagan (Eds.), The many colors of crime: Inequalities of race, ethnicity, and crime in America (pp. 138–156). New York: New York University Press. Desai, H. D., & Jann, M. W. (1999). Major depression in women: A review of the literature. Journal of the American Pharmacists Association, 40, 525–537. Dohrenwend, B. S., & Dohrenwend, B. P. (Eds.) (1974). Stressful life events: Their nature and effects. New York: Wiley. Francis, A., & Elias, S. P. (2017). Gender and mental health implications for social work education and practice. In M. Adusumalli & M. Anand (Eds.) Gender and social work: Positions and practices (pp. 138–162). New Delhi: Regal Publications. Geo, J., et al. (2019). First episode depression in women: A study of clinical characteristics through the female reproductive stages in a rural tertiary care center. Kerala Journal of Psychiatry, 32(1), 39–45. Gove, W. R. (1987). Mental illness and psychiatric treatment among women. In M. R. Walsh (Ed.), The psychology of women: Ongoing debates (pp. 102–118). New Haven: Yale University Press. Gove, W. R. (1972). Sex roles, marital roles, and mental illness. Social Forces, 51, 34–44. Gu, C.-J. (2006). Rethinking the study of gender and mental health. Graduate Journal of Social Science, 3(1). Retrieved from https://www.researchgate.net/publication/221935329_ Rethinking_the_Study_of_Gender_and_Mental_Health. Hagan, J. (1991). Destiny and drift: Subcultural preferences, status attainments, and the risks and rewards of youth. American Sociological Review, 56, 567–582. Heimer, K. (1995). Gender, race, and the pathways to delinquency: An interactionist explanation. In J. Hagan & R. D. Peterson (Eds.), Crime and inequality (pp. 140–173). Stanford, CA: Stanford University Press. Heimer, K., & De Coster, S. (1999). The gendering of violent delinquency. Criminology, 37, 277–317. Hill, T. D., & Needham, B. L. (2013). Rethinking gender and mental health: A critical analysis of three propositions. Social Science & Medicine, 92, 83–91. Elsevier. Howard, L. M., Ehrlich, A. M., Gamlen, F., & Oram, S. (2017). Gender-neutral mental health research is sex and gender biased. The Lancet Psychiatry, Series Women’s Mental Health, 4(11), 9–11. Jaramillo, J. C., & Restrepo-Ochoa, D. A. (2015). Normality and mental health: Analysis of a multivalent relationship. Journal of Psychology CES, 8(1), 37–46. Keyes, C. L. M. (2002). The mental health continuum: From languishing to flourishing in life. Journal of Health and Social Behavior, 43, 207–222. Kuehner, C. (2017). Why is depression more common in women than among men? The Lancet Psychiatry, Series Women’s Mental Health, 4(11), 146–158. Meyer, I. H., Schwartz, S., & Frost, D. M. (2008). Social patterning of stress and coping: Does disadvantaged social statuses confer more stress and fewer coping resources? Social Science & Medicine, 67, 368–379. Mirowsky, J., & Catherine, E. R. (1986). Social patterns of distress. Annual Review of Sociology, 12, 23–45. Muehlenhard, C. L., & Peterson, Z. D. (2011). Distinguishing between sex and gender: History, current conceptualizations, and implications. Sex Roles: A Journal of Research, 64(11–12), 791–803. Murray, J. L., & Lopez, A. D. (1996). The global burden of disease: A comprehensive assessment of mortality and disability from diseases, injuries and risk factors in 1990 and projected to 2020. Boston, MA: Harvard School of Public Health and World Health Organization. NIMHANS. (2016). National mental health survey 2015–16. Retrieved from http://indianmhs. nimhans.ac.in/Docs/Report2.pdf.

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Nissim-Sabat, M. (2013). Race and gender in philosophy of psychiatry: Science, relativism, and phenomenology. In K. W. M. Fulford (Ed.), The oxford handbook of philosophy and psychiatry (pp. 139–158). Oxford University Press. Open Learn University. (2016). Challenging ideas in mental health. Retrieved from https://www. open.edu/openlearn/health-sports-psychology/health/challenging-ideas-mental-health/contentsection-1.1. Patel, V. (2005). Gender in mental health research. Italy: World Health Organization. Rosenfield, S. (1989). The effects of women’s employment: Personal control and sex differences in mental health. Journal of Health and Social Behaviour, 25, 14–23. Rosenfield, S., & Mouzon, D. (2012). Gender and mental health. In Handbook of the Sociology of Mental Health (pp. 277–296). Elsevier. Rosenfield, S., & Smith, D. (2009). Gender and mental health: Do males and females have different amounts or types of problems? In T. L. Scheid & T. N. Brown (Eds.), A handbook for the study of mental health: Social contexts, theories, and systems (pp. 256–267). Cambridge, UK: Cambridge University Press. Ryle, R. (2015). Questioning gender: A sociological exploration. Thousand Oaks, CA: Sage Publications. Schippers, M. (2007). Recovering the feminine other: Masculinity, femininity, and gender hegemony. Theory and Society, 36, 85–102. Sibley, D. (1995). Geographies of exclusion: Society and difference in the west. London, Routledge. Simon, R. W. (2002). Revisiting the relationships among gender, marital status, and mental health. American Journal of Sociology, 107, 1065–1096. Sophie, H. L., & Graham, B. L. (2017). Why are women so vulnerable to anxiety, trauma related and stress related disorders? The potential role of sex hormones. The Lancet Psychiatry, Series Women’s Mental Health, 4(11), 73–82. Stanford Encyclopaedia of Philosophy. (2019). Mental disorder (Illness). Retrieved from https:// plato.stanford.edu/entries/mental-disorder/. Weissman, M. M., & Olfson, M. (1995). Depression in women: Implications for health care research. Science, 269, 799. https://doi.org/10.1126/science.7638596. Wizemann, T. M., & Pardue, M. L. (2001). Institute of medicine. Exploring the biological contributions to human health: Does sex matter? Washington: National Academic Press. World Health Organization. (2011). Gender mainstreaming for health managers: A practical approach. World Health Organization, Geneva. World Health Organization. (2013). Gender disparities in mental health. Department of Mental Health and Substance Dependence. Retrieved from https://www.who.int/mental_health/media/ en/242.pdf. Yu, S. (2018). Uncovering the hidden impacts of inequality on mental health: A global study. Translational Psychiatry, 8(98). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC5959880/. Zachrisson, A. (2019). Mental health—A normal state? The Scandinavian Psychoanalytic Review. https://doi.org/10.1080/01062301.2019.1693197. Zeiler, K., & Käll, L. F. (Eds.) (2014). Feminist phenomenology and medicine. Albany, NY: SUNY Press.

Contents

Part I

Conceptual Underpinnings for Gender and Mental Health

1

Understanding Gender and Mental Health . . . . . . . . . . . . . . . . . . . Nilima Srivastava and Meenu Anand

2

Gender, Depression and Emotion: Arguing for a De-colonized Psychology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bhargavi V. Davar

3

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3

Women with Mental Illness: A Psychosocial Perspective . . . . . . . . Saswati Chakraborti

33

4

Gender Roles in Mental Health: A Stigmatized Perspective . . . . . . M. S. Bhatia and Aparna Goyal

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5

Understanding and Locating Mental Health in a Cross-Cultural Context: Indigenous Community Perspectives . . . . . . . . . . . . . . . . Malathi Adusumalli

Part II 6

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Mental Health Scenario in India: A Gendered Lens

Mental Health Aspects of the ‘#MeToo Movement’: Challenges and Opportunities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . R. Srinivasa Murthy

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7

The Intersectionality of Gender, Disability and Mental Health . . . . Abhishek Thakur

8

Gender and Schizophrenia: Are Differences Biological or Social? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Ananya Mahapatra and Smita N. Deshpande

9

Urban Women and Mental Health Concerns in India . . . . . . . . . . 129 Vibhuti Patel

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10 Female Criminality, Mental Health & the Law . . . . . . . . . . . . . . . . 143 Saumya Uma Part III

Gendering Mental Health: Field Narratives

11 Psychosocial Rehabilitation—The Past, Current Approaches and Future Perspectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 Roy Abraham Kallivayalil and Sheena Varughese 12 Homelessness and Women Living with Mental Health Issues: Lessons from the Banyan’s Experience in Chennai, Tamil Nadu . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 Lakshmi Narasimhan, K. V. Kishore Kumar, Barbara Regeer, and Vandana Gopikumar 13 Tarasha’s Experience of Working with Women Living with Mental Illness: ‘Melee tar aamchi, Jagli tar tumchi’(‘if she dies she is ours, if she lives, she is yours’) . . . . . . . . . . . . . . . . . . . . 193 Shubhada Maitra and Ashwini Survase 14 Gender Differentials in the Presentation of Symptoms, Assessment, Diagnosis and Treatment of Mentally Ill Prisoners . . . 207 Mark David Chong, Amy Forbes, Abraham P. Francis, and Jamie Fellows 15 Gender and Community Mental Health: Experiences of Mehac Foundation—A Community-Based Mental Health Service in Kerala, South India . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223 Anupama V. Prabhu, Anu Sonia Vincent, Uma Parameswaran, and Chitra Venkateswaran 16 Practising Strength-Based Approach with Women Survivors of Domestic Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237 Gunjan Chandhok and Meenu Anand

Editor and Contributors

About the Editor Meenu Anand, Ph.D., is an Assistant Professor at the Department of Social Work, University of Delhi, India. She has an extensive professional experience and exposure in the areas of gender, education and mental health. Formerly with the Women's Studies & Development Centre, University of Delhi, she has also taught at Dr. Bhim Rao Ambedkar College, University of Delhi. Dr. Anand has been actively involved in working on issues related to gender, mental health and education for more than two decades. She has led various national and international projects focussing on multifaceted developmental issues during her specialized work experience with various grassroots NGOs. Dr. Meenu Anand also specializes as a trainer and conducts various capacity building and gender sensitization workshops for school, college and university teachers, journalists, police personnel, NGO functionaries and several other stakeholders. She has been instrumental in the development of curriculum at the Post Graduate level on gender for Women’s Studies and Development Centre, University of Delhi. She has an exaustive list of publications to her credit, in the form of books as well as research papers in national and international journals that seek to highlight issues related to gender, mental health and social work within interdisciplinary frameworks. Dr. Anand is passionate about working and researching on gender, education and mental health.

Contributors M. S. Bhatia, M.B.B.S.; M.D.; MNAMS, is currently the Director, Professor and Head, Department of Psychiatry, University College of Medical Sciences and Guru Teg Bahadur Hospital, Dilshad Garden. He is also the Head, Department of Psychiatry, University of Delhi. Prof. Bhatia is also the Editor of the prestigious Delhi Psychiatry Journal. He has written over 259 research papers, over 50 chapters and over 15 books in Psychiatry. Prof. Bhatia is the member of many National and

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International Organizations. He is also the member of review and editorial boards of many National and International Journals. Saswati Chakraborti works as a Psychiatric Social Worker at the Department of Psychiatric Social Work, Institute of Human Behaviour and Allied Sciences (IHBAS), Delhi. She has fourteen years of work experience at IHBAS, involved in Clinical Service Delivery, Rehabilitation and After Care of Persons with Mental illness; Training, Consultation and Research. She has published five Papers in National and International Journals and Books. Gunjan Chandhok is a Senior Research Scholar at the Department of Social Work, University of Delhi, pursuing her Doctoral research on ‘Influence of Intimate Partner Violence on Reproductive and Sexual Health of Women’. A topper of her batch (2016–2018), during her Masters in Philosophy in Social Work from University of Delhi, she researched on ‘Reproductive and Sexual Health Rights of Young Married Women in Urban Slum of Delhi NCR’. She has several years of grassroots experience of working in communities and organizations of repute. Her core areas of interest are Public Health and Gender Issues. In addition to Post-Graduation in Social Work, she also holds a Masters Degree in Gender and Development Studies. She has presented several papers at various National and International conferences and has prestigious publications to her credit as well. Mark David Chong is currently a Senior Lecturer in Criminology and Criminal Justice Studies as well as the Criminology. Major Coordinator for the Bachelor of Arts programme at the College of Arts, Society and Education, James Cook University (JCU), Australia. He was also formerly the Director of Research Education for the School of Arts and Social Sciences, JCU, from 2012 to January 2015. Through God’s Grace, in 2015 (and again in 2017), he was recognised for his ‘exceptional support for students with a disability’ through the university’s Inclusive Practice Award. He graduated with a Ph.D. in Law from the University of Sydney, where he received his Law School’s Longworth Scholarship (2003), the Cooke, Cooke, Coghlan, Godfrey and Littlejohn Scholarship (2004), the Longworth Scholarship for Academic Merit (2006) and the Longworth Scholarship once again in 2007. He was appointed as a Judicial Referee by the President of the Republic of Singapore on the recommendation of the Chief Justice to the Small Claims Tribunals’ bench. However, given his deep interest in criminal justice issues, Mark subsequently taught the Singapore Police Force and the Central Narcotics Bureau at Temasek Polytechnic, Singapore, under a joint academic programme with Queensland University of Technology, Australia. Of late, Mark has begun to develop expertise in converging criminology and social work through the specialisation of criminal justice social work in India. In this regard, he has published works that pertain to human rights, mental illness and strengths-based practice. Bhargavi V. Davar is a childhood survivor of the Indian mental asylums, being exposed to a variety of them for years in early childhood. Compelled by those early experiences, she completed her Ph.D. in 1993, from the Indian Institute of

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Technology, Mumbai on the ethical and epistemological foundations of the mental and behavioural sciences. Through her early years, she studied theories of freedom and consciousness, human physiology, psychology, buddhism, ‘anti-psychiatry’, and the philosophies of social sciences. Her research has been on gender, culture and disability studies, and making sense of modern mental health policy frames in India and Asia. The impact of colonialism on mental health systems in post colonial times, in India, is also a big area of research interest. She has published works, including (co-author) Psychoanalysis as a Human Science (Sage, 1995); Mental health of Indian women (Sage, 1999); (ed.) Mental health from a gender perspective (Sage, 2001); Gendering mental health: Knowledges, identities, institutions (OUP, 2015). She is Director of the Bapu Trust for Research on Mind and Discourse, Pune; and Convenor for an Asia advocacy platform, called ‘Transforming Communities for Inclusion, Asia Pacific’ (TCI Asia Pacific). She is a practising Arts Based Therapist and teacher; an international certified trainer of the UNCRPD; and an organic farmer. She lives with her daughter in Pune, India. Smita N. Deshpande, MD (AIIMS), DPM (Bombay) is a Professor of Psychiatry. She is a leading researcher in schizophrenia genetics, interventions and disability with numerous nationally and internationally funded research projects and publications to her credit. She led the Department of Psychiatry at Centre of Excellence in Mental Health, ABVIMS-Dr. RML Hospital for over 14 years and now heads the National Coordinating Unit of ICMR for NMHP Projects, leads the Resource Center for Tobacco Control and heads the Central India Unit of UNESCO Bioethics Chair Haifa at the Centre of Excellence in Mental Health which she initiated and established. Jamie Fellows is a Senior Lecturer at the Law School at James Cook University, Australia and has been there since 2009. Since then he has taught and published in areas of public law, particularly on topics regarding criminal sentencing, legal history, and war crimes. Jamie’s Ph.D. topic investigates the US Army war crimes trials of the Japanese conducted in Manila after the Pacific War. Jamie lectures and coordinates compulsory and elective subjects within the LLB degree programme across the Townsville and Cairns campuses at JCU. Jamie’s teaching is informed by proven pedagogical approaches to student learning that utilises a variety of scaffolded and blended-learning teaching practices. For a number of years Jamie has been involved in the St. Vincent De Paul Volunteer Refugee Assistance Program in Townsville. Prior to commencing at JCU, Jamie held several positions within the private and public sectors in Japan and Australia. Amy Forbes is Associate Professor of Communication and Journalism, and is also Associate Dean, Learning and Teaching for the College of Arts, Society and Education at James Cook University. Her research interests are in the areas of intergenerational communication, emotional and mental health issues in migrant and indigenous communities, gaming and social capital formation, and advances in digital communication and design.

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Abraham P. Francis is an Associate Professor, and currently the Head of Academic Group in Social Work and Human Services at James Cook University, Australia. He has worked with Government, Non-government and corporate sector, and has developed many international partnerships. He taught social work at the Delhi University in India and worked as a senior mental health social worker with Country Health South Australia before moving to Townsville to join James Cook University. Dr. Francis has extensively contributed to the literature on Social Work practice in mental health through his publications, convening conferences, establishing research networks and by developing consortiums. His other research interests are in the field of communities, criminal justice, international social work, and gerontological social work. In 2018, Dr. Francis received the NAPSWI (National Association of Professional Association Social Workers in India) lifetime achievement for his outstanding contribution to social work Education. Vandana Gopikumar (The Banyan, BALM and TISS) co-founded The Banyan, and The Banyan Academy of Leadership in Mental Health (BALM) and has for two and a half decades focussed on developing appropriate and comprehensive mental health services that are person centric for disadvantaged groups, especially homeless persons and those living in poverty. Dr. Gopikumar is also Professor, School of Social Work, Tata Institute of Social Sciences (TISS) and Appointee, non-official member, Central Mental Health Authority under Mental Health Care Act, 2017. She was also a member of the first Mental Health Policy Group constituted in 2012. Vandana’s research interests include exploration of lived experiences of homelessness and mental illness, transitions in societal perceptions and conceptualisations of mental ill health based on social mores, social contact and cultural legacy; Assessing outcomes and impact of care models that address concerns of persons with severe mental disorders; understanding impact of adverse life events on mental ill health and recovery; childhood trauma, suicide and self-harm; notions of human rights, subjective well-being, resilience and self-directed therapy/recovery; community inclusion and exclusion etc. She is deeply interested in mentoring peer advocacy movements, particularly from low-income groups and homeless persons, seldom represented in global policy discourses. Aparna Goyal, M.B.B.S.; DPM; DNB is a Senior Resident with the Department of Psychiatry at University College of Medical Sciences Guru Teg Bahadur Hospital, Dilshad Garden, Delhi. She is also a member of the Journal Committee, Delhi Psychiatry Journal and many national Organizations. Roy Abraham Kallivayalil is Professor and Head, Department of Psychiatry, Pushpagiri Institute of Medical Sciences, Thiruvalla, Kerala. He is President of World Association of Social Psychiatry (Paris) and the Secretary General of the World Psychiatric Association, Geneva. He was President of the Indian Psychiatric Society and Associate Editor, Indian Journal of Psychiatry. He received ‘Best Doctor Award’ from Government of Kerala. President of India presented him the

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World Federation of Mental Health (WFMH) Award for meritorious services to the cause of Mental Health in 2017. He has more than 60 publications in peer reviewed scientific Journals. K. V. Kishore Kumar is the Director of The Banyan and BALM. Earlier, he was a Senior Psychiatrist at the National Institute of Mental Health and Neuro-Sciences (NIMHANS) Bangalore, India, for 25 years, where he headed the Community Health services in the Department of Psychiatry. He has served as an Advisor to the Indian Government in developing a Policy for ‘prevention of corporal punishment’ and providing relief centres for the homeless. Dr. Kumar has also advised the World Health Organization (WHO) on mental health services in Somalia. He is actively involved in clinical practice and community care and works with homeless persons with mental illness in Government institutions. His areas of interest include community mental health services; training primary care doctors and general practitioners; Care of the Homeless with mental ill health; Life Skills for adolescents; Psychosocial issues of disasters; Psychosocial rehabilitation of the mentally ill in rural areas using local resources; Economics of mental health; Epidemiology of mental disorders; functioning and disablement among persons with schizophrenia. He has published research papers extensively in national and international journals. Ananya Mahapatra, MD (AIIMS, New Delhi), is currently working as Assistant Professor at the Centre of Excellence in Mental Health, ABVIMS-Dr. RML Hospital. She is a recipient of Samuel Gershon Young Investigator Award by the International Society of Bipolar Disorders (ISBD) and Michael Hong Travel Award by Asian Society of Child & Adolescent Psychiatry and Allied Professions (ASCAPAP). Her areas of interest are social psychiatry, severe mental disorders, and child and adolescent psychiatry. Shubhada Maitra is Professor and Dean, School of Social Work, Tata Institute of Social Sciences, Mumbai. She has an M.A. in Medical and Psychiatric Social Work, TISS, Mumbai and a Ph.D. in Social Work from Mumbai University. Her areas of interest include mental health, gender, sexuality and violence with a focus on women and children. She is the Faculty-in-Charge of two field action projects of TISS: Muskaan, the child and adolescent guidance centre of TISS and Tarasha, that works towards recovery and reintegration of women living with mental illness. She functions as an external member on committees for prevention of sexual harassment at the workplace for several large corporate organisations based in Mumbai with business all over India. She has contributed several articles to national, international journals and edited volumes. Malathi Adusumalli is an Associate Professor with the Department of Social Work, University of Delhi and has vast experience in the field of community development. She has authored a number of articles and contributed to the knowledge volumes in Social Work. Her doctoral work was in the area of Development Studies and she has continued her research interests in the state of

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Uttarakhand, particularly with disaster affected communities. Her interests are in the fields of social development, gender development, social policy and social research. Lakshmi Narasimhan has a Masters in Social Work and has been working in the homelessness—mental health space since 2005 with The Banyan. She leads the implementation and research of projects aimed at quality of life gains using community-based approaches to mental health. Dr. Narsimhan has served as the principal investigator and project lead for action research projects at The Banyan. These include NALAM, a well-being oriented, multi-interventional, tiered clinical and social support service spearheaded by community mental health workers; and Home Again, a housing with supportive services intervention offering exit pathways out of institutionalised care for persons with severe and persistent mental illness. She is currently engaged in a multi-site community re-entry programme to address issues of long stay and incarceration in institutional facilities. Her interests are in understanding and developing social approaches for complex issues at the intersection of poverty, homelessness and mental health. Uma Parameswaran has completed M.Phil. in Clinical Psychology and is currently working in a research project. Vibhuti Patel is Professor, Advanced Centre for Women’s Studies, School of Development Studies, Tata Institute of Social Sciences, Mumbai. She retired as Professor and Head of Economics Department of SNDT Women’s University, Mumbai on 30-6-2017. She was Director, Post Graduate Studies and Research of SNDT Women’s University from 2006 to 2012. Her areas of specialisation have been Gender Economics, Women’s Studies, Human Rights, Social Movements and Gender Budgeting. She has authored Women’s Challenges of the New Millennium (2002. She is co-editor of series of 15 volumes—Empowering Women Worldwide. Her edited books are Discourse on Women and Empowerment (2009) and Girls and Girlhoods at the Threshold of Youth and Gender (2010). She had been a member of various Expert Committees for IGNOU, Ministry of Science and Technology and NCERT (Delhi) during 2005–2014. Anupama V. Prabhu is a Psychologist and Special Educator, has 9 years of experience in community based psychological care. She is involved in conducting various awareness sessions to different segments in community. Anupama also has experience in dealing children with special needs. Barbara Regeer is Assistant Professor at the Athena Institute, VU University Amsterdam. She has Bachelor degrees in Physics and Philosophy and a Master’s degree in Science Dynamics. She has analysed and developed interfaces and interactions between science and society in various ways throughout her career. She conducts her research on emerging innovative strategies for sustainable development. Dr. Regeer has been involved in numerous (inter-) organisational change processes, with a specific focus on enhancing learning between all actors involved, in such areas as sustainability innovation programmes (agriculture, urban

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development, mobility), care farming, disability mainstreaming, youth care organisations, and psychiatric institutions. She has initiated the development of Translearning and other reflection tools such as the Dynamic Learning Agenda and Eye-opener workshops. R. Srinivasa Murthy has been a full time academician/researcher from the time of completion of postgraduate training in 1975. He was a faculty member at PGIMER, Chandigarh (1975–1981) and the National institute of Mental Health and Neurosciences (NIMHANS) Bangalore (1982–2003). Prof. Murthy was Professor of Psychiatry at NIMHANS, from 1987 to 2003. He was Head of the Department of Psychiatry, from January 1988 to February 1997 with over 50 postgraduates and 40 academic staff. He has been a much-respected teacher and mentor to many of the current leaders in psychiatry in India. He was a staff of World health Organisation (WHO) during 2000–2001 (Chief Editor, World Health Report, 2001-Mental Health) and 2004–2006 (in the WHO-EMRO Office). Since retirement, he has provided honorary services to non-governmental organizations like the Association for the Mentally challenged, (AMC) Bangalore (2008–2014), Sri Shankara Cancer Hospital and Research Centre (SSCHRC), Bangalore (2015–2016). He was awarded the Distinguished Scientist Chair of Indian Council of Medical research, (ICMR), New Delhi in May 2016. Currently working to develop and disseminate ‘self-care skills’ for emotional health with a special focus on persons living with a diagnosis of cancer and HIV-AIDS. Nilima Srivastava is a Professor and currently the Director with the School of Gender and Development Studies, Indira Gandhi National Open University, New Delhi. Her area of specialization is women and work. She has researched extensively on work-life balance of women workers in International and national context in diverse settings. She has written three books and published a number of research papers in national and international publications. She was a visiting Professor to University of British Columbia, where she carried out a micro level research to study impact of Federal and Provincial Governments’ child care policies on working mothers in Vancouver. Ashwini Survase is working as Project Manager with Tarasha since 2012. She has completed her Masters in Counselling from TISS, and a Bachelors in Psychology and Sociology from Mumbai University. She is currently pursuing a Doctoral Degree from Advanced Centre For Women’s Studies, TISS. Before joining Tarasha, she worked as a counsellor with a daycare Centre for persons recovering from mental health issues. Her interest areas are mental health, gender and marginalization. Abhishek Thakur is currently teaching at the Department of Social Work, University of Delhi, India. He has completed his Masters and M.Phil. degree from Tata Institute of Social Sciences, Mumbai. His research interests include Disability Studies, Labour and Employment.

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Saumya Uma is an Associate Professor at the Jindal Global Law School and has previously taught in the School of Law, Governance and Citizenship—Ambedkar University Delhi, Maharashtra National Law University, Mumbai and National Law School of India—Bangalore. Her areas of specialization are human rights, gender and the law. She has over 25 years’ of combined professional experience as an advocate, researcher, writer, trainer, campaigner and academic. Dr. Uma is a life member of the Indian Association for Women’s Studies and an active member of the women’s movements in India and in the South Asian region. Sheena Varughese is currently working as Assistant Professor, Department of Psychiatry, Pushpagiri Institute of Medical Sciences, Thiruvalla, Kerala. She had completed her MD Psychiatry from St. Johns Academy of Health Sciences and Medical College, Bangalore. Her area of interest includes Child and Adolescent Psychiatry and Addiction Psychiatry. Chitra Venkateswaran is a Professor of Psychiatry and Palliative care physician. Having wide experience not only in Kerala, working initially in the WHO collaborating centre in Calicut but also as a trainer and mentor across India. Active role in work that highlights an important perspective on the neglected area of chronic mental health and palliative care with its priority area within NCD programmes. She holds the role of founder/clinical director of Mehac Foundation, a not for profit based on a palliative care model. Mehac strives to deliver exceptional care to improve the quality of life of people with mental illnesses in the community. The goal is to improve the psychosocial component in any person with a special interest to facilitate integration of psychological issues in palliative care. Anu Sonia Vincent has M.Phil. in Consulting Psychology, and has hands on experience working with student community and their families. She has around 5 years of experience working at school as counsellor. She is presently working as psychologist at Mehac.

Abbreviations

AAA ACT AD ASHA BPAD CM CRPD DALYs DHS DOSMeD DSLSA DSM ECT FGD GTBH ICD ICIDH ICM IDI IHBAS LAMI LGBTQIA+ MEHAC MHA MTP NGO NHRC NMHS

Ashray Adhikar Abhiyan Assertive community treatment Alzheimer’s disease Accredited Social Health Activist Bipolar affective disorder Case management Convention on the Rights of Persons with Disabilities Disability-adjusted life years Directorate of Health Services Determinants of Outcome of Severe Mental Disorders Delhi State Legal Services Authority Diagnostic and Statistical Manual Electroconvulsive therapy Focus group discussion Guru Teg Bahadur Hospital International Classification of Diseases International Classification of Impairments, Disabilities, and Handicaps Intensive Case Management In-depth interview Institute of Human Behaviour & Allied Sciences Low and middle income Lesbian, Gay, Bisexual, and Transgender Queer, Intersex and Asexual Mental Health Care and Research Foundation Mental Healthcare Act Medical Termination of Pregnancy Non-governmental organization National Human Rights Commission National Mental Health Survey of India

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PMDD PMS PPD PTSD RPDA SE SHG SMI SSRI SZ UDHR UNCRPD UNFPA WHO

Abbreviations

Premenstrual dysphoric disorder Premenstrual stress syndrome Post-partum depression Post-traumatic stress disorder Rights of Persons with Disabilities Act Supported employment Self-help group Severe mental illness Selective serotonin reuptake inhibitor Schizophrenia Universal Declaration of Human Rights United Nations Convention on the Rights of Persons with Disabilities United Nations Fund for Population Activities World Health Organization

List of Figures

Fig. 1.1 Fig. 12.1 Fig. 15.1 Fig. 16.1

Social determinants of mental health . . . . . . . . . . . . . . . . . . . Proportion of men versus women in long-stay service-users at state psychiatric hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . Concept of the model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Seven key principles of strength practice . . . . . . . . . . . . . . . .

..

6

.. .. ..

175 228 238

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List of Tables

Table 12.1

Table 12.2 Table 12.3 Table 12.4

Background characteristics of women admitted to emergency care and recovery centre (ECRC), The Banyan, 2014–2017 (n = 203). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Admissions and discharges from the emergency care and recovery centre (ECRC) 2014–2017 n = 203 . . . . . . . . . . Clients reintegrated from ECRC and length of stay by year of admission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Current aftercare status of clients discharged to families/facilities outside . . . . . . . . . . . . . . . . . . . . . . . . . . .

180 181 182 183

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List of Boxes

Box 3.1 Box 6.1 Box 6.2 Box 6.3 Box 8.1 Box 8.2 Box 8.3 Box 8.4

Gender Disparities and Mental health: The Facts (WHO 2020) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Recent headlines of the times during #METOO movement . . . . . 7 Habits that women must learn to change (Narayan 2018) . . . . Seven Levels to address male–female relationships that promote mental health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Biological Differences among Men and Women with SZ . . . . . . Government Entitlements under of Disability Certification . . . . . Key points: Social Differences among Men and Women with Schizophrenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Role of a Social Worker in Ensuring Gender Parity . . . . . . . . . .

35 80 85 91 114 115 120 122

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Part I

Conceptual Underpinnings for Gender and Mental Health

Chapter 1

Understanding Gender and Mental Health Nilima Srivastava and Meenu Anand

Introduction Gender is a critical determinant of mental health and mental illness. The morbidity associated with mental illness has received substantially more attention than the gender specific determinants and mechanisms that promote and protect mental health and foster resilience to stress and adversity. Gender also determines the differential power and control men and women have over the socioeconomic determinants of their mental health and lives, their social position, status and treatment in society, and their susceptibility and exposure to specific mental health risks (WHO 2014b).

Mental health is understood as ‘a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community’. It is the capacity of the individual, the group, and the environment to interact with one another in ways that promote subjective well-being, the optimal development and use of mental abilities (cognitive, affective, and relational), the achievement of individual and collective goals consistent with justice and the attainment and preservation of conditions of fundamental equality (WHO 2001, 2013). Positive mental health includes self-realization, mastery of one’s environment, and having autonomy (Jahoda 1958). Mental health is therefore fundamental to good health and quality of life and a resource for every-day life and an essential component of social cohesion, productivity, and peace and stability in the living environment, contributing to social capital and economic development in societies (WHO 2004a, b). Understood N. Srivastava School of Gender and Development Studies, Indira Gandhi National Open University, New Delhi, India e-mail: [email protected] M. Anand (B) Department of Social Work, University of Delhi, New Delhi, India e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2020 M. Anand (ed.), Gender and Mental Health, https://doi.org/10.1007/978-981-15-5393-6_1

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as critical to ensuring healthy transitions to adulthood, positive mental health has implications for overall well-being, growth and development, self-esteem, positive education outcomes, social cohesion and resilience in the face of future health and life changes (UNICEF 2012).

Mental Health: A Biomedical Approach? Mental health is determined by biological, psychological, social, economic and environmental factors which interact in complex ways, so identifying direction of causality is rarely straightforward (Barry 2009, p. 8). There are various models/approaches that are predominantly put across in the context of mental health and illness. Prominent among the popular discourses is the biomedical model of mental health that links the prevalence of mental disorders with biological phenomena, such as genetic factors, chemical imbalances, and brain abnormalities (Anand 2018; Wyatt and Midkiff 2006). Contesting the biomedical model of understanding mental illness Davar (2008) wonders ‘Whether medicine is at all the best panacea for mental disorder needs to be examined in detail. There are no biological markers for the spectrum of mental disorders. Psychiatry, unlike medicine, is a statistical and infant science, developed only in the 1940s. … There are correlations of symptoms with populations (for example, higher incidence of anxiety and neurotic disorders in women), but no biological or aetiological research to explain those correlations in a biologically comprehensive way’ (as cited, Davar 2008, p. 353). The development of DSM is considered more like a ‘treaty negotiation than a scientific deliberation’ (Licky and Gordon 1991, p. 48). The social and environmental aspects of mental health become “incorporated into the genetic or the neural, absorbed into the body as a comorbidity or epigenetic ‘trigger’” (Decoteau and Sweet 2016, p. 430). Within this paradigm, the social world and its complexities thus appear as reconfigured into a set of stressors acting on the body/brain, thus becoming a “risk or a ‘trigger’ for what is essentially a brain-based disorder” (Bayetti et al. 2016). Furthermore, keeping in mind the limited resources, the government psychiatric hospitals and departments must operate in what Addlakha (2008) calls an ‘acute model of management’ (p. 97), in which practitioners’ ‘clinical work demand an instrumental stance’, and an almost ‘impossible mandate requir[ing] that they discharge patients quickly, and yet treat them adequately’ (p. 99). The enhanced thrust on sole medicalization of health has been studied by Bayetti et al. (2016) during their research with post graduate students of psychiatry. They put forth arguments with respect to mental ill health being reduced as a simple product of mental disorders with clear neurobiological origins, which in turn also assumes that health can be regained through the use of technological instrument and health interventions comprised of ‘series of discrete treatments targeted at specific syndromes or symptom[s]’ (Bracken et al. 2012, p. 430). The dominance that the biomedical model of illness and the technological paradigm had within the ‘formal

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curriculum’ also means that other forms of mental health care, including psychosocial interventions, were mostly neglected.

Socio-cultural Determinants of Gender and Mental Health Determinants of mental health and mental disorders include not only individual attributes such as the ability to manage one’s thoughts, emotions, behaviours and interactions with others, but also social, cultural, economic, political and environmental factors such as national policies, social protection, living standards, working conditions, and community social supports (WHO 2013). The social determinants of mental health cumulatively impact across the life course, and how they are experienced by populations who have greater exposure to risk factors, and lesser access to opportunities to protect their mental health (Mental Health Foundation 2015). Mental health problems can result from the complex and dynamic interplay between individual attributes and behaviours (e.g. emotional and social intelligence), social and economic circumstances (e.g. experienced social support, poverty, education opportunities), and wider socio-cultural environmental factors (e.g. social and economic policies at the national level, discrimination). These aspects interact with each other in a dynamic way that can either protect, or pose a risk to, mental health (Droogenbroeck et al. 2018) (Fig. 1.1). Diagram on social determinants of mental health adapted by Mental Health Foundation (2015) from the WHO European Review of Social Determinants of Health and the Health Divide in the European Region. Original source: World Health Organisation (2014a). Social determinants of mental health. World Health Organisation publications, Geneva, Switzerland. Ogundare (2019) highlights the role of culture in the conceptualization of mental illness and the phenomenology of mental illness across cultures. It is an etiological determinant of mental disorder; it shapes the perception of self and reality. Culture influences how individuals’ manifest symptoms, communicate their symptoms, cope with psychological challenges, and their willingness to seek treatment (Gurung 2019; Kovess-Masfety et al. 2001). The majority of human behaviours are heterogeneous, and the classification into signs and symptoms occurs for the sake of diagnosis, treatment, prognosis, public health policies and to enhance professional communication (Fabrega 1987; Manderson et al. 2009). Culture is therefore central to the aetiology of mental disorders as it provides standards for normality and abnormality, and the definitions of what constitutes a mental disorder are socially and culturally negotiated (Aderibigbe and Pandurangi 1995; Paniagua and Yamada 2013). It determines the variations of normalcy in behaviours; while some cultures are tolerant of high levels of deviant behaviours, other cultures insist on conformity (Paniagua and Yamada 2013). Marsella and Yamada (2010) identified several ways in which culture influences psychopathology in terms of the patterns of physical and psychosocial stressors, the types and parameters of coping mechanisms and resources used

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Fig. 1.1 Social determinants of mental health

to mediate stressors, basic personality patterns including, but not limited to, selfstructure, self-concept, and need/motivational systems, the language system of an individual, especially as this mediates the perception, classification and organization of responses to reality, standards of normality, deviance, and health, treatment orientations and practices, classification patterns for various disorders and diseases, patterns of experience and expression of psychopathology, including such factors as onset, manifestation, course and outcome (as cited in Ogundare 2019).

Gendering Mental Health Gender is conceptualized as a structural determinant of mental health and mental illness that runs like a fault line, interconnecting with and deepening the disparities associated with other important socio-economic determinants such as income, employment, and social position. Whether we are male or female shapes our access to resources and our life choices and options. It colours the ways we relate to others, what people expect of us, and what we expect of ourselves. Clearly, then, this division should affect our internal states and compasses: the way we feel about ourselves, how

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we experience the world, and our emotional reactions. Because our social practices are fundamentally gendered, mental health and emotional troubles should also differ for men and women (Rosenfield and Smith 2012; Astbury 2000). Gender is a critical determinant of health, including mental health. The social construction of gender is one of the underpinnings of mental health. Going beyond physical differences in brains and bodies, an exploration of the areas of culture and development, across the lifespan and across the globe, can provide some context for a better understanding of mental health, and illness, and the complex and varied social worlds that make up the lives of women and men, families and communities (Andermann 2010). Gender influences the power and control men and women have over the determinants of their mental health, including their socio-economic position, roles, rank and social status, access to resources and treatment in society. As such, gender is important in defining susceptibility and exposure to a number of mental health risks. If it is accepted that both women and men have a fundamental right to mental health, it becomes impossible to examine the impact of gender on mental health without considering gender-based discrimination and gender-based violence. Consequently, a human rights framework can enable the interpretation of gender differences in mental health and in identifying and redressing the injustices that lead to poor mental health. Infact, many of the negative experiences and exposures to mental health risk factors that lead to and maintain the psychological disorders in which women predominate involve serious violations of their rights as human beings including their sexual and reproductive rights (WHO 2013). Furthermore, a gendered approach to mental health is critical to distinguish biological and social factors while exploring their interactions, and to be sensitive to how gender inequality affects health outcomes (Affifi 2007). Astbury (2000) also found that gender differences in mental disorders extend beyond differences in the rates of various disorders or their differential time of onset or course and include a number of factors that can affect risk or susceptibility, diagnosis, treatment, and adjustment to mental disorder. Examining the reasons why women outnumber men in the population that has mental problems, Gu (2006) describes the gender differences in personal characteristics (such as vulnerability, personality traits, self-concepts, coping strategies and available resources) and their effects on mental health and also the structural factors that produce gender inequality in society. Family structure, employment status, housework load, multiple roles and poverty exemplify these structural factors. Gender differentially affects the power and control men and women have over the socio-economic determinants, their status, roles, treatment in society. According to Davar (1999a), “gender is not just about the ‘male’ and ‘female’. Gender is about power and powerlessness, and about the masculine and the feminine, but the interplay between these analytical categories is quite complex and of feminist interest in theorizing gender. Gender is an analytical formulation about an individual or a certain class of people as masculine or feminine within the context of certain existing power relationships” (cited p. 174). Davar (2008) argues “… For feminism, ‘abnormality’ is both patriarchal and psychiatric labelling leading to the exclusion of women. All women’s behaviour not conforming to patriarchal norms, including

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insanity, was to be understood as protest. Evident in collections of women’s stories, writings and archives, the emotional subtext was totally patriarchal. Women’s spaces for personal anger, anguish, suffering or disability were politicised in the women’s movement. These personal spaces were seen as socially constructed and instrumental for political ends, namely, the challenge to patriarchy” (as cited on p, 339). Davar (1999b) also examines research on women’s mental health and synthesizes a bio-psychosocial model. Rejecting the reductionism of any single dimension of this model, she calls for a sophisticated understanding of women’s mental distress that takes into account complex contextual factors, especially psychosocial causes. Likewise, Gu (2006) proposes a diamond-shaped model to understand mental health that includes biomedical, psychological, social and cultural factors of mental distress. The biomedical and psychological aspects constitute the individual dimension of mental health, while social (e.g. systems, organizations, systems of stratification, social positions and relations) and cultural (e.g. symbols, meanings, values) factors make up its structural facet. Gender norms can reinforce girls’ and women’s unequal position in relationships, which can reduce their abilities to negotiate their rights. Evidence from diverse countries demonstrates that exposure to gender discrimination, physical and emotional abuse, violence, poverty, social exclusion, educational disadvantage, harmful gender norms and psychological stress that accompanies humanitarian crises can all increase mental health problems, including depression (Landstedt et al. 2009; Reiss 2013; Aggarwal and Berk 2014; Rhodes et al. 2014; Kagesten et al. 2016). In most countries, girls are at greater risk than boys for all these precursors. Indeed, while gender inequalities affect the lives of both boys and girls, they disproportionately disadvantage girls. Gender-specific risk factors for girls can include unequal access to resources, decision-making power and education; gender-based violence; and discriminatory practices such as child marriage (Le Strat et al. 2011; Rhodes et al. 2014). These risk factors interact with culture and socio-economic circumstances to elevate exposure and vulnerability to health risks, such as depression, self-harm, and suicide. Other research finds that negative, humiliating, or entrapping interpersonal events can join social stress in precipitating women’s depression (Broadhead and Abas 1998; Patel et al. 2001; Brown 2002; Kessler 2003). As Kimmel (2004) points out, gender also determines structures of social power: Gender is not simply a system of classification by which biological males and biological females are sorted, separated and socialized into equivalent sex roles. Gender also expresses the universal inequality between women and men. When we speak about gender, we also speak about hierarchy, power, and inequality, not simply difference (2004, p. 1; as cited in Francis and Elias 2017).

The political economy approach that interlinks social, political, and economic factors that impair women’s health, emphasizes on the structural factors and power relations that produce inequalities in well-being, two phenomena that have been overlooked in sociological studies of mental health. The anthropology of mental health, or what some anthropologists call ‘cultural psychiatry’, highlights the importance of cultural meanings in the labelling of both mental illness and abnormal behaviour.

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Its proponents argue that the social production and distribution of health and illness cannot be separated from larger social, economic, and medical systems. As a social system dominated by men and medical/scientific knowledge, the medical setting is an arena within which power relationships are omnipresent (Gu 2006).

Differential Manifestations of Mental Illness Sex-differentiated mortality and morbidity patterns begin to emerge during adolescence, with variations in some cases due to differences in biological and environmental risk factors and interactions (Blum et al. 2014; WHO 2017). Both girls and boys are affected by social norms and expectations based on their gender and sexuality. Gender role differentiation increases during adolescence, and discrimination based on gender also intensifies during this critical phase of development (Petroni et al. 2015). Rigid gender norms can profoundly and negatively affect both girls and boys and can particularly constrain girls’ aspirations and opportunities. They can influence girls’ ability to travel or attend school, the places they can and cannot go in the community, and the nature and types of social interactions they are permitted to engage in. Boys are more able to move freely about and thus have greater opportunities than girls to participate in society and in income-generating activities (Lundgren et al. 2013). Mental disorders commonly emerge during the adolescent years, influenced both by the biological, emotional and cognitive processes associated with puberty and by the social contexts surrounding adolescents as they mature through this important phase of life (Patton et al. 2016). Recent large-scale epidemiological studies have assessed the rates of mental disorders among women and men. There are gender differences in particular types of psychiatric disorders. Women’s mental health cannot be considered in isolation from social, political and economic issues. Women also exceed men in internalizing problems of anxiety and depression. An examination of women’s position in society reveals that there are sufficient causes in current social arrangements to account for these. Women have more of both milder and more severe forms of depression, as well as most types of anxiety, including generalized anxiety disorder and phobias. Greater depression means that more women than men live with feelings of profound sadness and loss, serious problems with negative self-concept, and feelings of guilt, self-reproach, and self-blame. Women experience a great loss of energy, motivation, and interest in life more often than men. Greater anxiety means that women suffer more often from fears of specific objects or situations (i.e. phobias), panic attacks, and free-floating anxiety states that attach themselves to seemingly random thoughts and situations (Gajendragad 2015). Furthermore, there are also certain types of disorders that are unique to women. For example, some women may experience symptoms of mental disorders at times of hormone change, such as perinatal depression, premenstrual dysphoric disorder and perimenopause-related depression (National Institute of Mental Health 2019).

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There also seems to be a vicious cycle of adversities in the case of women. Women who are poor and those who are less educated are also found to be at increased risk of poor mental health. Similarly, women living in poverty are disproportionately affected by social exploitation. These women face various types of social, physical, and economic hardships, which in association with the experience of domestic violence increase their vulnerability to mental morbidities (Patel et al. 1999, p. 49). Counts et al. (1992) found that where women have a higher economic status they are seen as having sufficient power to change traditional gender roles, and it is at this point that violence is at its highest. Both community surveys and hospital-based studies indicate that women are disproportionately affected by mental health problems and that their vulnerability is closely associated with their marital status, work, and roles in society. Consultation with the mental health professionals for the female members of the family is less often than that noted for the male counterparts (Gajendragad 2015). Rehabilitation after the treatment of mental illness also has gender dimensions as there are gender differences in bringing the patient back to the home/community (Moorkath et al. 2018). In the Indian scenario, a man is always treated as an asset wherein families try to accommodate men even though with difficulty, and the wife or parents will act as a source of support to them. However, for the women, the situation is entirely different as they are abandoned, consistently blamed, frequently questioned about the illness; and if married, shuttle between the family of origin and the family of procreation. Consideration of women’s mental health therefore requires recognition of the impact of social factors on mental health, a position that challenges traditional biomedical approaches to mental illness. Discussions on health issues pertaining to women have largely addressed the biological and reproductive factors. However, women’s well-being is apparently beyond biological factors and reproduction. The issues like workload, stress, migration, and nutrition are equally important (Counts et al. 1992). Women’s mental health determinants intersect with other marginalized positions of disadvantage, in particular those clustered around structures of racialization and class. The social determinants of health for women include factors such as poverty, education, employment, homelessness, isolation, inequality, social constraints and violence. Women are often not in a position of autonomy or decision-making. Rugkhla (2009) rightly identifies the social pressures on women and states that ‘women are largely responsible for ensuring positive outcomes in reproductive health, parenting, domesticity and formal employment, but are often not the principal decision makers in these realms’. These sociocultural factors have differential impacts on women’s mental health outcomes (Babacan 2014, p. 232). Gender-specific risk factors for common mental disorders that disproportionately affect women include gender-based violence, socio-economic disadvantage, low income and income inequality, low or subordinate social status and rank, and unremitting responsibility for the care of others (WHO 2012). Thus, there is a need to consider and contextualize factors like poverty, violence as they have a profound impact on the mental health of women.

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Poverty and Mental Health Studies have confirmed that women’s greater exposure to poverty throughout their lives occurs for a variety of reasons, including lower levels of education, receiving lower rates of pay, doing more part time work and ‘casual’ work and consequently, being less likely to be able to amass adequate savings or superannuation for a financially secure old age (De et al. 2017). Findings of a study by Trani et al. (2015, pp. 8–9) establish that intensity of multidimensional poverty is higher for persons with severe mental illness than the rest of the population, Deprivation of employment and income appears to be major factors contributing to multidimensional poverty. Lack of employment and income tends to aggravate mental illness. Similar linkages are made by Heise and Garcia-Moreno (2002) who too reiterate that poverty acts as a marker for a variety of social conditions that combine to increase the risk of violence faced by women. Women in better jobs than their husbands are also found to be more at risk of poor mental health, a feature that is not unique to India. Furthermore, Robertson and Winkleby (1996) argue that although homeless women may not have major mental illnesses, but homeless women exhibit disproportionately high rates of major mental disorders and other mental health problems. Research also indicates that though familial and spousal and social support parameters were more adverse in urban women, reproductive health problems and their association with poor mental health were strikingly more common in the rural populace.

Linkages with Reproductive Health Mental health and reproductive health are closely related wherein women in the reproductive age group are especially vulnerable to the occurrence of mental problems as many studies have shown that adverse reproductive health outcomes are linked to poor mental health (WHO 2009; De et al. 2017). The close relationship of reproductive health and mental health and their overall impact on the health of women in this age bracket is significant, due to the influence this bears on the rest of the family and the children (WHO 2004a, b). Women’s reproductive role as bearer and nurturer of children and the varied roles produce unique potential for stress-related effects. Women’s unique roles in reproduction, the family and society, their often lowers socio-economic status, necessitate special considerations for their mental health.

Impact of Violence Gender-based violence is also associated with a higher prevalence of mental health problems. Sexual assault at any age is closely associated with depression and anxiety disorders, and women who have experienced sexual assault either in childhood or

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as adults are also more likely to attempt suicide than other women (Kapungu and Petroni 2017). Women’ s mental health requires the elimination of violence and discrimination based on sex, age, income, race, ethnic background, sexual orientation or religious beliefs. Trani et al. (2015, pp. 9, 10) strongly suggested that stigma linked to various marginalized groups have the power to accelerate and intensify exclusion and related discrimination. For women, severe mental illness can negatively impact well-being in two ways. First, severe mental illness limits women from fulfilling family and social roles, leading to these women being considered a burden for the family. Traditional beliefs (punishment for previous lives, evil eye/curse), as well as negative lay attitudes on causes and behaviours, lead to increased discrimination of and sometimes violence against SMIs, particularly for women. Passive violation in the form of neglect by families is far more than noted. Incidences of active violation include physical, mental as well as sexual abuse. Mentally ill women are commonly and repetitively abused with rape and other sexual assaults, as well as physical violence. The regular forms of trauma, domestic violence, sexual abuse, vulnerability, stigma and victimization faced by women also have an impact on the mental health (Gajendragad 2015, p. 39).

The Issues of Men and Transgender In the context of men, cultural expectations of ‘what it means to be a man’ may lead boys to engage in risky and health harming behaviours, such as early and heavy smoking and use of alcohol and illicit drugs (UNICEF 2012). For boys, endorsement of stereotypical masculine norms has been associated with substance abuse, delinquency, perpetuation of interpersonal violence, and reduced help-seeking (Rhodes et al. 2014). Men are seen more frequently exhibit externalizing problems of substance abuse and antisocial behaviour, which are more destructive and problematic to others. Greater substance abuse means that men more often consume excessive amounts of alcohol and other drugs—in both quantity and frequency—than women. They more often experience extreme physical consequences from substances, such as blackouts or hallucinations. Drugs or alcohol interfere with their lives more often, causing problems at work or in the family. They are therefore, at a greater risk of antisocial behaviour including disruptive disorders in childhood and adolescence— such as attention deficit/hyperactivity disorder, conduct disorder, and oppositional defiant disorder—as well as antisocial personality disorder in adulthood (American Psychiatric Association 2000). Similarly, men are encouraged to suppress, are less concerned with relationships, and are generally verbal and emotional economists; they employ a more suppressive instrumental style of coping, which is likewise consistent with their sex-specific biology, cultural conditioning, and the roles they must perform (Francis and Elias 2017). Furthermore, the inclusion of trans perspective within the discourses of gender is a progressive step towards embracing unorthodox changes. With the decriminalization of Article 377 of the Indian Constitution (that earlier treated homosexuality as a

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criminal offence), recognition of right of trans persons to get education as well as employment; India has indeed advanced ahead broadening its gender horizons (Anand 2019). Inclusion of a transfeminist perspective suggests that trans might be central, not marginal, to gender and women’s studies (Enke 2012). However, this calls for a much greater enquiry with respect to the mental issues of LGBTQAI+ that may be beyond the scope of this paper.

Conclusion Gender differences in mental health status and their social determinants have drawn considerable attention in the field of mental health. Gender considerations in health promotion and health care have to highlight the mental health risks and the socioeconomic and cultural determinants of mental health. Although, economic independence, safety (physical and sexual), and security are primarily needed for good mental health, but the same are supposedly denied to most of the women by virtue of their status as women. Such gender-based discrimination is not only a gross violation of human rights but directly contributes to the growing burden of disability caused by poor mental health (Srivastava 2012, pp. 1, 2) The gender stereotypes are rampant across cultures bounded with discriminations, restrictions, and instructions toward women, further worsened the condition of women. Women’s mental health is strongly associated with their status in society; it benefits from equality and suffers from discrimination (WHO 2001; Chandra et al. 2009; Moorkath et al. 2018). The role of socio-cultural factors impacting mental health needs to borne in mind while devising mental health promotion policies. It is important to focus on creating supportive environments, reducing stigmatization and discrimination, and supplementing the social and emotional well-being of service users and their families (Barry 2009, pp. 6–7). Mental health professionals have a very significant role in creating awareness across the communities and reduction of stigma, involving various stakeholders. There is also an alarming need to bring gender-sensitive policy-level initiatives and effective community rehabilitation programs for bringing a positive change in the lives of homeless women with chronic mental illness (Moorkath et al. 2018, p. 477). Thus, mental health concerns of women, men as well as LGBTQIA+ must be considered within the context of their social position and cannot be achieved without equal access to basic human rights. Therefore, issues related to autonomy, education, safety, economic security, property and legal rights, employment, physical health including sexual and reproductive rights, access to health care and adequate food, water and shelter assume immense importance. The intersection between culture, gender, and mental illness must be considered at all levels within policy, research, and ultimately, front-line services (Andermann 2010). There is also a pressing need to document the various cultural definitions of well-being and mental health recovery from a gender perspective. This enquiry must move beyond traditional psychiatric

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spaces and must encompass a wide range of social actors across multiple sites, and a cross-fertilisation of disciplines such as medical anthropology with mental health to develop more grounded concepts, theory and emerging practices (Bayetti et al. 2016). Therefore, it is critical that the legal framework should go beyond safeguarding quality of care for all and include an early access to effective treatment and prevention. Implications of ensuring this fundamental human right also means that specific needs of individuals get assessed and met at individual, familial, and social levels. This requires the need to recognize the specific needs of all the groups, namely women, men, children, disabled, religious and ethnic minority groups, lesbian, gay, bigender and transsexuals, and all others who are at higher risk and have the vulnerability of acquiring mental disorders (Bhugra et al. 2015, p. 119). A proportionately targeted approach to both treatment and prevention level is needed while planning and budgeting for the overall planning for health care. Thus, there is increasing recognition throughout the world of the need to address mental health as an integral part of improving overall health and well-being (WHO 2001, 2002, 2005) as health behaviour points to the entwined nature of physical and mental health and to achieve wider health and social gains effective strategies have to be devised for mental health promotion.

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Chapter 2

Gender, Depression and Emotion: Arguing for a De-colonized Psychology Bhargavi V. Davar

Medicalizing Women’s Lives Depression is known as a ‘mood’ or ‘emotional’ disorder. Yet, in clinical writings, linking depression, purportedly a contagion by now, to a theory of emotion is not found. This lack of theory underlying practice is particularly disempowering for women who self-identify as being depressed, overly emotional, feeling an emotional overwhelm, etc., and seeking healing remedies. This gap in ‘meaning making’ of personal experiences within the healing disciplines, also compromises the choices on offer for supporting women who may express a need for such support. Psychiatric practice in India is oriented towards chemical cures (anti-depressants), and colonial cures (segregation and restraint). The paper attempts to theorize emotion vis-à-vis gender and the social construction of ‘depression’. There is the need to question views which see women’s emotions as a primitive, ‘psychosomatic’ and inferior way of responding to life problems, and as mental pathology. Of particular interest to this paper are the colonial assumptions behind psychiatry. Norms of diagnosis and therapy, presented as ‘modern’, are confounded by unexplored historically constructed gender and culture bias, and institutional designs that have not changed in centuries (Davar 2014). Three ideas behind the western construal of emotion, through colonial formation of psychology, are questioned here from the gender/cultural perspective: (1) emotion is universal (2) It is in the individual; (3) emotion in mental. These ideas are presumed in most frameworks for addressing needs of women with psychosocial distress, disturbance or I thank Prof. William Sax, and the University of Heidelberg for providing me with a one year Fellowship grant to explore the colonial aspects of psychology and psychiatry in India. This paper is drawn from research done on the grant, allowing me to travel and visit various libraries and archives in the country. B. V. Davar (B) Bapu Trust for Research on Mind & Discourse, Pune, India e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2020 M. Anand (ed.), Gender and Mental Health, https://doi.org/10.1007/978-981-15-5393-6_2

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disability. A sub-altern view, as suggested by this paper, validates the local, communal and embodied aspects of emotion, as evidenced by women’s narratives of their experiences. Historically, the prevalence of depression in the community has been flagged off as alarmingly high, since the 1970s through the 1990s.1 For example, Sethi et al. (1972), Chakraborty (1990, 1996), Isaac and Kapur (1980), Sharma (1987), and a host of medical writers (critically reviewed in Davar 1999a) raised an alarm about prevalence ranging from 10% up to 40%. Prevalence of depression was also reportedly high in people seeking general health care. In all of these data, gender was a significant variable, with women always showing a higher occurrence of depression in diverse Indian epidemiological samples (also see Channabasavanna and Seshadri 1987; Dube 1970; Khanna et al. 1974; Nandi et al. 1977, 1979, 1980; Raju et al. 1980; Sethi and Prakash 1979; Sharma 1987; Venkoba Rao 1969). Several factors are linked to the causes of depression among women, which can be described broadly as social disadvantage, gender discrimination (reviewed in Davar and Ravindran 2015), including poverty, caregiving, disadvantage at work, domestic violence, discrimination due to sexual orientation, ageism, ablism, etc. However, the ‘cures’ for social inequality, extant discrimination and exclusion in the literature were bio-medical, where medical treatment was first priority. By the 1990s and early 2000, and through the next two decades, the topic of ‘untreated depression’, especially among women, was very popular among the new emerging psychiatrists, who often worked in spaces outside of the traditional public health institutions in India (example, Patel et al. 1999 and passim). Worldwide, too, the literature on mental health evidenced higher prevalence and lifetime risk for depression among women (Desjarlais et al. 1995; Goldberg and Huxley 1992; Hirschfeld 1987; Kessler et al. 1993; Russo and Green 1993; Weissman et al. 1993). In this period, there was the systematic translation of several physical and embodied idioms of women’s psychosocial distress into a psycho-pathological language of depression. Complaints of vaginal discharge, back pain, chronic fatigue, common ‘genital complaints’, ‘somatoform complaints’, menstrual distress, etc., became algorithms for diagnosing psychiatric problems, without addressing the associated social determinants and how that impacted their physical health and overall well-being (e.g. Patel et al. 2006a, b). A certain argument in this literature is common, that women were reporting physical ailments, but actually, they had depression or some other ‘common mental disorder’. In other words, they were ‘psychosomatic’, also named pathologically as ‘somatisation’. Such women were considered hysterical, a nuisance in OPD and emergency settings, or as good subjects for various spurious medical cures including needless surgeries (For a critique of ‘somatisation’, see Kawanishi 1992). At the same time, through a putative ‘secularization’ process, cultural healing practices of dalit, tribal and indigenous peoples, such as shamanism, spirit possession, trancing, oracular functions, mediumship, exorcism, koranic healing and other ‘native’ treatments were weeded out or recast as psychopathology (Davar and Lohokare 2009; Davar 2014; Sood 2016). Attention also shifted to a ‘bio-psychosocial’, ‘lifespan’ approach, with early interventions, bringing a wider spectrum of women within medical treatment settings. By 2010, global mental health agendas

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were talking about the ‘alarming rise of mental disorders’, especially among women. In the year 2000, the World Health Organization published a unique report on ‘Women’s Mental Health’.2 The WHO has been promoting the view that depression is the second most disabling disease, coming just after cardiac disease, linking mental disorder with social disadvantage, and advocating for treatment. Mental disorder is also now recognized globally as a non communicable disease (NCD), requiring treatment for severity and chronicity, like diabetes, cancer, autoimmune disorder, etc. Writers, publishing prolifically in open access journals from the Global Mental Health Movement, made it a moral imperative on governments to ‘fill the mental health treatment gap’ (Patel et al. 2006c). Baxter et al. (2013) among others have raised challenges to the data on the ‘alarming rise of mental disorders’. The market value of ‘NCDs’ is analysed by Katz (2013), among others. See Mills (2013), Mills and Fernando (2014), Summerfield (2008, 2012) on strong critiques of globalizing mental health and the political economy of this, particularly for the global south. Post 2000, a series of medical papers argued mainly that depression can be treated effectively with low-cost anti-depressants in low- and middle-income countries (LMIC), many studies showing better outcomes when compared with other modalities which had placebo effects (Patel et al. 2005a, b; Patel et al. 2006c; Patel et al. 1999, 2001, and passim). While the methodology of such research has been challenged, findings of the prevalence of depression continue to be statistical, not linked to a disease pathway (unlike other physical medical conditions). The ‘chemical imbalance’ theory of depression, among other mental disorders, is widely used to convince patients and families that these medications have a sound basis in basic anatomy and physiology. However, since the 1990s, the severe hazards caused by psychotropics, particularly anti-depressants, are becoming well known. For example, psycho-pharmaceutical companies are now placing a black box warning on antidepressant use in the case of children and young adults, due to high suicidal risk. A high-level advisory to the British Government, led by Davies and Read (2019), evidenced alarming damage to health and well-being by SSRIs. Also, see the damning evidence around the political economy of psychiatric drug use and the vested interests of insurance companies in the USA (Kirsch 2009; Whitaker 2010). The bio-medical etiologic basis of major depression until date was never proven. The understanding of psychosocial distress, disturbance and disability has seen a steep change in this millennium, towards over-medicalization, psychiatrization of social justice issues, increasing occurrences of institutionalization against free will and consent, as well as a considerable restriction of women’s choices for self and healing. The feminist aspects of understanding it from an experience centric, social determinants and human rights and justice point of view is vanishing fast. Media coverage fuelled by the confessions and the faith of several celebrities (Honey Singh, Deepika Padukone, etc.) has pushed forward the medical view that ‘depression’ is like an intractable physical disease and a commitment to lifelong medication is a must, to live well. In this paper, and elsewhere in my work, depression is understood to be a distressing psychosocial experience and is more commonly experienced by women. The subjective and disabling aspects of depression, its causes and conditions within

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human habitats, ecologies and life circumstances, and methods of self-healing or healing through support, comes through in various first-person accounts (for example, recently, in Indian literature, by Breckenridge and Kathait (2019). Writing close to the experience of psychosocial distress and disturbance requires some reflections on phenomenological methodologies (Davar 2000). The different positionalities with respect to the experience of psychosocial distress and disturbance from a feminist perspective are described in Davar (2008). Depression may not be a state of abject victimhood. But neither is it a state of total agency and empowerment. It is a state where a woman protests her (bodily, social and spiritual) circumstances. Yet she is unable to directly negotiate her situation or effect action that she can call her own. She is often left with a bundle of intense experiences, physical pain among other embodied experiences of distress, making her preoccupied with her own physical health twined with her own experience of over-emotionality; she may also experience a heightened sensitivity to people, their existential situation and a deep preoccupation with human life, questions of morality, care and purpose, which is the subject matter of spiritual quests (Davar 1998). ‘Recovery’ often involves defining the moral, spiritual quest more closely, if necessary, aesthetically, and finding doors, if at all, opening for a ‘will to live’ and to live well (Davar 2007).

Women’s Mood and Its Colonisation Three questions about emotion bind the reflective concerns of this paper: (1) that emotion is universal, (2) emotion is in the individual, (3) and emotion is mental. Broadly, this section is a critique of views that hold emotion to be universal, individualistic and mental, while the remaining sections aim to establish that emotions are valued and held by communities as an embodied, communally held natural resource for healing. “Depression” is considered a mood disorder (Costello 1976). This is a problem of naming experiential state that come as a mix of anxiety, shame, guilt, sorrow, rage, helplessness, hopelessness and other. Mood is also bliss, mania, euphoria, joy, expansiveness, devotion and sensing the sacred, but psychology has not focused on these. Indeed, some of these emotions are also seen with the lens of psychopathology. Mood is described in emerging psychological literature as the ‘weather of the soul’ (Loosmore 1928: 19). Psychologists (Ortony et al. 1988) describe emotion as a valenced pre-verbal reaction to the world. It is a being- or a state-marker concerning events, agents or objects. It is said to occur within a person, in the realm of the psyche (as opposed to soma). Emotion has been contrasted, and unfavourably opposed to reason and rationality, as if, when reason fails, emotions, often negative or depressive, take over. Emotions are judged as chaotic, unpredictable, negative, but having a ‘signalling function’ of an individual’s life disrupted of its structure, as describing a state of internal chaos, ready to burst out if untethered:

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…(W)e should use emotional episodes as signals which indicate that we should examine the patterns of our activities. Only when the pattern has been modified in some way, will the general negative valence, its repelling property, cast over our world by the emotion, be removed and the pleasure in our activities be regained. (Costello 1976: 13)

From an existential point of view, ‘mood’ is the colour of a self and its experience. Emotion is said to be a ‘form of human existence’ (Sartre 1971: 28), resulting in the overall ‘transformation of the world’ (Sartre 1971: 63) for an individual. Psychologists tried to show that emotion has a universal, logical structure linked to mental representation, intentionality, personality, language and social action and is a dark and dangerous sibling of thought. Thinkers have tried to make emotion mirror thought, by showing that it has structure. Emotion, also said to be a mental event like thought, is argued to have a referential object, arising about items or events of the world (Gordon 1987). For example, ‘I am so angry about what happened yesterday’. Emotion is said to have a sentence structure, like a thought, therefore within the cognitive realm: ‘I am sad’ has the same linguistic structure as ‘that table is brown’. Emotion is argued to be part of a causal story: We invariably use ‘because’ to explain expressed emotion. For example, ‘I am sad because she did not reciprocate my feelings for her’. Like thoughts, emotion is ‘perlocutionary’; i.e., it results in action (Coulter 1986). For example, ‘I was so angry that I smashed the bucket’. Emotion is easily attributed in every-day social behaviour. We are able to predict others’ emotions. For example, ‘He appears sad today’. Emotion is intentional and learnt through a developmental process (Jaggar 1989; Kaufman 1993). Following such translation of emotion into universal cognitive schemas, a conceptual realm of the mental evolved, and individual therapies, for example, retraining of emotional responses (behavioural approaches). The existential model stresses the ‘thereness’ of emotions and the need for acting out, as if emotion is a spoilt, toxic drink that needs to drained out of the bottle. Cognitive approaches bring disturbing emotions under the oversight of reason and thought process. For example, Lazarus (1993) details the relational cognitive themes grounding different human emotions. Levy (1984) analyses emotions by reducing them to (1) an elicitor event, (2) an experienced feeling (3) and a cognitive appraisal of the feeling. Through the process of rationalizing each stage, disturbing emotions are brought under the purview of reason. In humanistic therapy, depressive emotion is bad faith, inauthenticity or false consciousness. Sartre refers to emotion as a ‘debasement’ of consciousness (1971: 79). Sartre suggests that depressive people use their emotion to escape from rational action (1971: 68–69). Sartre’s analysis of a woman’s ‘weepiness’ as a type of escapism and a drift from the authentic self is particularly problematic. Therefore, in psychology, derived from the intellectualism of enlightenment and the celebration of reason, emotion was undervalued as an inferior mental faculty, though however ‘controllable’. The corpus of essays presented in Schweder and Levine (1984) questions the universalist emphasis on reason in psychology. A further translation happened in India due to the colonial process, in the emerging colonial literature of psychology of the late nineteenth century (Davar 1999b).

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Influenced by psychoanalysis, ‘native’s’ emotions were characterized as ‘primary process’, ‘symbolic’ process, ‘instinct’; ‘primary’, ‘cultural’, ‘unconscious’, ‘primitive’ and ‘savage’. For example, Ribot wrote: It has been observed, in general manner, that the lower races are not very sensitive to pain. The Negroes in Egypt endure, almost without suffering, the most extensive surgical operations…it may be admitted without hesitation that susceptibility to pain increases with civilization… (1897: 36).

“Moral insanity”, a diagnosis of emotional disorder was commonly made by the emerging psychologists. This diagnosis was not only a value judgment about individuals who failed to conform or contribute to the emerging middle-class industrialized world order, but it was also a judgement about culturally inferior ‘natives’. Forbes (1813) analysed Hindu religious practices as having all the wrong emotions or no emotions for upholding a superior moral life. Depression was seen as a classic case of degenerate morality. Paradoxically, moral insanity was said not to be present in the colonies, since natives were not seen as having any moral sense, but rather as just cruel, noisy and libidinous, and low on the human evolutionary scale. Budding Indian psychologists such as Mitra (1932), influenced by the colonial view, proposed a ‘new theory of emotions’ that favoured ‘harmony’, ‘homeostasis’ and ‘even-temperedness’ (anandam). See Davar (1999b), for an analysis of the colonial, patriarchal basis of Indian psychology and psychoanalysis, as it was emerging in late colonial and post-independence period. A universalist psychology, which colonialism escalated, has gender implications. Reason became equivalent to the masculine and emotion, to the feminine (Jaggar 1989). Emotions were described as not only something inferior to reason, but also as something like a woman, volatile, uncontrolled, lusty and physical/bestial. Scientific activity, as rational, public activity, became gendered and masculine, which view has left a telling mark on the growth of psychology as a discipline. The evolving scientific definition of insanity stressed the value of reason over emotion. Jaggar writes: Not only has reason been contrasted with emotion, but it has also been associated with the mental, the cultural, the universal, the public and the male, whereas emotion has been associated with the irrational, the physical, the natural, the particular, the private and, of course, the female. (1989: 151)

Lutz and Abu-Lughod (1990) presented a collection of essays that examine the gender politics in the social construction of emotional practice. Women’s emotion is a capital resource that is manipulated by society for its own, often economic, if not commercial ends (Hochschild 1983). In western literature, therefore, emotion, native and women are inter-defined—as natural, private, irrational, chaotic, subjective and physical; and not public, ordered, universal or rational. These writings seek to expand our critical understanding of the historical role played by emotion theories in the social regulation of women in the colonial and post-colonial period in India. Hoch (1963, 1965 and passim) writes disparagingly of the Santhal tribe, observing their ‘mutism’ and a penchant to live in a state of emotional opacity, with stoic and unrelenting embodiment of all things mental and moral.

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Lutz examines a range of therapeutic and other scientific literature that projects the disabling view that women are emotional by nature. Women themselves are often seduced by this view and may structure their lives accordingly. Lutz and Abu-Lughod (1990) studied the role of emotions in ordinary American talk. The study shows that women, more than men, are thinking in terms of ‘control’ of their emotions, even though they were not making more emotional statements than the men. Such studies have implications for supporting women who may feel emotional overwhelm. For example, a women dealing with her husband’s extra-marital relationships may make her ‘emotional problems’ the focus of conflict, rather than confronting the problem with the husband. With increasing ‘awareness’ on depression and its medical treatment, there is the risk that these sociological processes undermining women’s agency by naming emotional expression as pathology will become more widespread. Views, such as ‘Women are by nature more emotional; their emotions are tied to their bodies and hormones; women need to be taught rational ways of controlling their emotions’, etc., which are already embedded within the psychiatric and therapeutic discourses, will become entrenched in clinical practice.

Sub-altern Gendered and Cultural Discourses of Emotion There are a few culturally popular stories about emotionally expressive women which do not cast emotion or its embodied expression, as pathological, but rather, as liberating, for example, the Tamil Sangam literature protagonist, Kannagi. Kannagi destroyed an entire city, Madurai, in profound grief, betrayal and rage, following her husband Kovalan’s unjust murder by an otherwise judicious king. Kannagi’s rage stands as a huge metaphor of emotional expression, sadness and fury, bringing public shaming and community retribution for a single unjust act. Also, imagine the power of a resolutely furious woman, recently widowed, raging through the alleys of a revered city, using the sheer physicality of her anger, to burn it down. There is also the neeli (weeping soul) myth and folk lore in Tamil Nadu. This is a proverbial folklore of a woman who could be said to be ‘depressed’ by her husband’s adultery. The community supported her by condemning the husband. Eventually, unable to withstand her weeping, grieving, rage, unreflective of his moral transgression and ignoring society’s contempt for a neglectful, adulterous husband, he kills her. Her unhappy soul materializes into a ghost, which henceforth avenges all injustice done to women. The folklore is proverbial. Many a colloquial phrase and adage refer, both to the emotionality of a neeli, as well the symbolic, destructive power that her tears have, other than her power to consolidate a community morality around adultery.3 The gendered politics of emotion, the communal, embodied, economic and other negotiations that happen around it, are vividly sketched in Mahasweta Devi’s famous story, Rudali (Devi 1997). In this story, Sanichari is a low-caste woman paid to cry in the death ceremonies of the upper-caste Rajputs. This is a role given to low-caste women in the Rajput community. Sanichari mocks the pretentiousness of the latter

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by devising a sectioned pay scale for embodying and performing grief. The men, who actually organize and preside over the death ceremonies, cannot cry. That is an offense to their masculinity. The upper-caste women are in veil (ghoongat). They are not agentive in the public realm, while they may well be powerful within their households, exercising their power over other younger women and children. So, their tears have no functional value to the community and do not reinstate prestige, honour and power for the men. Low-caste and ‘public’ women—(women ‘kept’ and later discarded by the Rajput men)—are hired to cry. The greater the rudali’s modulation of publicly enacted grief, the more prestige the men get in their community. All this is good for Sanichari’s business. She has different ‘rates’ for simply crying; crying and rolling on the ground; crying, rolling and beating the breast; crying, rolling, beating the breast, and hitting the head on the ground, etc. Her defiance and ‘manipulativeness’ was not from a site of power, but of consummate poverty; and an urgency regarding her very survival. She survives by offering and precisely manipulating her body, as well as the ‘community of sentiment’ surrounding death and grief. She monopolizes the bereavement business with her emotionality, the sheer physicality of it, the invitation to the community to be audience if not participant, and she becomes a leader of sorts for the marginalized public women. Here was a woman who ‘never shed a tear’ for her dead mother-in-law, husband and son, nor for her absconding (daughter-in-law) bhuu and grandson. But her ‘resilience’ consisted in cleverly using the ‘women are emotional’ paradigm to her own absolute advantage. In doing so, she subverted that very paradigm. In such widely prevalent legends, myths, folk lore and stories, there are some common tropes. The emotional overwhelm is in relation to an experienced grievance or loss. There is a communal context, where the community is not just objective witness to the emotional overwhelm but are participating audience and agents. Social justice elements are involved, in the community emotional drama, the community being the platform upon which social justice is enacted, often in an intensely physical, embodied way. Descriptions of Kannagi’s wrath in the Tamil literature evoking the tremendous rage she carried in her body, and its different parts (e.g. hair), and its breaking all gendered norms of public display, is legendary. Neeli, the weeping ghost, can mystically appear and disappear within a context of social, gender and communal justice, confounding the very materiality of the body. Sanichari’s grief is wildly embodied and subverts the patriarchal norms on the private/public, and the subversion of the confinement of women and body in a traditional culture. An enduring theme through these stories is that of power, gender and emotion, while subverting the extant view that women are emotional and weak. Women expressing themselves without inhibition are positioned as powerful avengers, leveraging the full uninhibited expression of their bodies and yet, acting as moral guardians of their families and communities. From a cultural point of view, emotion as a social practice is significant in nonwestern contexts, where cultural scripts do not privilege individuality. In India, unlike in the west, emotion was a part of the discourse on aesthetics (the rasa theory) and not only of therapuetics (Paranjpe and Bhatt 1997). Emotion was linked with the positive, expressive and creative aspects of human experience and community living,

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than with the lonely, negative, destructive and disturbed. An ‘Indian’ view of emotion would not stress the introspective, individual and cognitive aspects, but rather the communitarian, public and intuitive aspects of emotion. In this view, an expressed emotion has an infectious quality and happened in the interconnected space when everyone collects together, drawing every bystander into an experiencer. The emotion binds individuals together vis-à-vis communitarian goals. The communitarian nature of emotion in the Indian context, and its transformation through post-colonial modernity, is written about by several authors (Appadurai 1990; Lynch 1990; Paranjpe and Bhatt 1997; Pieterse and Parekh 1997; Sundararajan 1997). These writings highlight the role imperialism played in regulating ‘Indian’ and women’s emotion in different socio-historical contexts, splitting and splicing a communal resource and reassembling them as something residing in the individual. The changeover of a ‘traditional’ society to ‘modern’ India must have involved a sustained and strenuous regulation of the emotional realm through the missionary, reformist, as well as the colonial political processes. Such transformation of emotion, that is, the subtext of colonization and its continuation in the post-colonial reconstruction of Indian nationality and mentality, is yet to be fully researched. An individualistic theory of emotion privileges individual difference. In a sociocentric theory, emotion binds communities; Emotions make individuals of a community, experience belonging, serving the goals of consolidating and sustaining group identity. Appadurai discusses the concept of a ‘community of sentiment’ among the hindus. It is within a shared community life that certain emotional gestures make sense, for example, ‘prembhav’ or ‘praise’: …(P)raise is not a matter of direct communication between the ‘inner’ states of the relevant persons, but involves the public negotiation of certain gestures and responses. When such negotiation is successful, it creates a ‘community of sentiment’ involving the emotional participation of the praiser, the one who is praised, and the audience of the act of praise. (1990: p. 94).

Praise within the ‘community of sentiment’ creates a ‘generalized sense of adoration or wonder’. This binds the community. Appadurai writes further: “…(T)he emotional landscape implied by such acts of praise is not built on the idiosyncratic, biographical, experiential, ‘inner’ feelings of Western common sense” (1990: p. 109). Emotions are a part of public negotiations. Indian communities maybe said to possess emotional conclaves for consolidating community identity through negotiating feelings. The community practices related to bereavement are yet another example. In most Indian communities, grief following loss is not ‘private’ and silent, as in the West, but public and noisy. It is a time not only for sharing grief, but also for coming together, reconciliation, consolidating caste identity. That emotions are inner, explosive and must be dammed is a western metaphor. In the non-western context, emotion is more like a community well that can be shared. Emotion can be shared, pooled, reused and distributed. It must however not be forgotten that even in the latter metaphor, there are rules about who can or cannot share in the well’s resources. From an Indian perspective, it is important to differentiate a culture centric theory of emotion from the available

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person-centred west. However, in doing so, the gendered politics determining the regulation of emotion should not be ignored.

Conclusion Western therapy actively simulated ‘therapeutic communities’ (Jansen 1980) and other community safety nets for emotional expression, for example, ‘Soteria’. Here, disturbing emotions maybe released in actual or symbolic play within a group context supervised by a psychiatrist. Such spaces, though non-medical, have always been available in most non-western countries, for example, the phenomena of spirit possession found in several Asian cultures. The use of sensory expression, especially through rhythm (dhol), fragrance, visual forms of colour, form and creation, opening the voice box (song, chant) and moving the body (for example, crawling through small openings, circumambulations, rolling on the floor in devotion, or other strenuous physical activities) are commonly found in many indigenous healing rituals. The therapeutic value of performing emotion through shared ritual behaviour, often enacted in public with active community participation and the use of creative arts, is of interest to healing frameworks (Scheff 1979; Davar and Lohokare 2009). In recent times, particularly in the emerging literature on healing from trauma, the role of the body as the holder of distress and as the vehicle for healing is certain knowledge (van der Kolk 2015), following works by Peter Levine and his legacy on somatic healing. Recent research on body-based healing suggests that resourcing the body through certain body repertoires (including yoga, trance rhythms and arts based expression) can be therapeutic. Verbalization enhances difference, but nonverbal repertoires enhance interconnection. A non-verbal response to distress leaves the experience unnamed, as an undifferentiated social phenomenon that happens. It elides neat categorization as bodily/mental. As the gestures and the evoked feelings are shared by or even orchestrated by the community, they are not further labelled as private/public; normal/deviant; rational/moody, etc. There are, for example, no elaborate rules and scripts for ‘social rehabilitation’ following a possession episode, as there is in the case of social deviance. Through such embodied performances, women can be subversive, expressive and creative, while ‘mad’, and yet not stigmatized or isolated. Depression is the ‘automatic pilot’, a survival programme activated under emergency situations. It is the result of a choice, conscious or otherwise, made to live life at a particular intensity. The emotions that underlie depression are those that contribute positively to experiencing sensitivity to our social and spiritual connectedness, to nature and to our cherished relationships. Depressed women are also those who agonize over the everyday morality of their lives, often at profound cost to themselves. They are not ‘divided selves’. Rather they are women making extra efforts to ‘be all there’, as fully embodied beings capable of care, to whom it may be right to say, in intervention contexts, ‘do not try so hard’. Women’s emotions in

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depression must be theorized and intervened with accordingly. Particularly questionable are colonial, medical and sexist perceptions of women’s emotion as regressive and bestial. The individualistic and mentalistic basis of these positions must be reexamined. A communitarian theory of emotion must be more fully articulated to provide the cultural basis for women’s depression, its acceptance and relief, if that is an expressed need. End Notes 1. Psychiatric diagnosis as such, and the early manual of DSM (DSMI) was released in 1962, in the post colonial reconstruction period. 2. WHO/MSD/MDP/00.1. 3. I thank Roja Muthiah Research Library, Chennai, for making materials from their archives available to me for this paper.

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Chapter 3

Women with Mental Illness: A Psychosocial Perspective Saswati Chakraborti

Introduction Women’s health is inextricably linked to their status in society. It benefits from equality, and suffers from discrimination. Today, the status and well-being of countless millions of women worldwide remain tragically low. As a result, human well-being suffers, and the prospects for future generations are dimmer (The World Health Report by WHO 1998, p. 6).

Gender is denoted as a process of understanding socially constructed roles, behaviours and identities of being a woman or a man and how people perceive themselves in relation to one another in society and the life experiences they go through (Chandra 2019). Simone de Beauvoir (originally in 1949) referred to the patriarchal discourse as ‘masculine ideologies that do not in any way express feminine claims’ and identified the construction of women as the Other (de Beauvoir 2011 pp. 182). In this context, therefore, Lundgren et al. (2013) argue that the attitudes and behaviours that lead to gender equality are developed through a socialisation process that begins right at birth. The gender norms/as well as the social reproduction of these norms takes place in societal institutions through cultural practices. Ganterer and More (2019) argue Today, most parents or professionals do not explicitly mean to raise girls to femininity and boys to masculinity; they unconsciously act upon generalised concepts of feminine and masculine (Rendtorff 2006). In other words, they embody gendered knowledge and pass it on to children who then again embody their lifeworld experience. Liebenwein (2008), for example, found in her research that parents in all kinds of social milieus, employing diverse parenting styles, raise their children gender-specifically. What precisely people define as female or male depends on, in addition to general, comprehensive tendencies, aspects such as culture and milieu (Demmer 2013, as cited in Ganterer and More 2019, p. 163).

S. Chakraborti (B) Department of Psychiatric Social Work, Institute of Human Behaviour and Allied Sciences (IHBAS), Delhi, India e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2020 M. Anand (ed.), Gender and Mental Health, https://doi.org/10.1007/978-981-15-5393-6_3

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The gender norms are therefore imbibed by girls and boys during socialisation, and these in turn are directly related to their consequent behaviour that affects health, and the ensuing quality of life (Greene and Barker 2011). This also implies that the norms around sexual relationships, fertility control, the use of physical violence, and alcohol and drug use, are also strongly influenced by gender norms which determine how men and women interact with their partners, families, and children (Interagency Gender Working Group 2011). The gendered attitudes and behaviours imbibed by men and women also include an understanding of ‘how aspects like help seeking, trauma, early childhood adversities, nutrition and physical health are all influenced both by gender and sex’ (Chandra 2019). A psychosocial understanding on mental health, therefore, gains significance keeping in mind the differentials of gendered socialisation. Despite an increased awareness in the contemporary socio-cultural milieu, people continue to stage gender in conventional, dichotomous manners, meaning male-being refers to hardship, strength and courage while female-being correlates with dependency and vulnerability (Mogge-Grotjahn 2015 as cited in Ganterer and More 2019). These are evident in the compartmentalisations in the lives of most women and men, viz. masculine and feminine traits, roles associated with child bearing and rearing, ‘double shifts’ (at home and at work) and the lack of autonomy in personal, working, economic, social, professional and political relationships. These experiences indeed have an impact on the self-esteem, sense of mastery and mood (Koblinsky et al. 1993). The psychosocial approach towards mental health and illness looks at individuals in the context of the combined influence that psychological factors and the surrounding social environment have on their physical and mental wellness and their ability to function. It explores the role of socio-economic position, access to resources and social status among women which in turn influences mental health. As noted by WHO (2000) A gendered, social determinants model offers the only viable framework for examining evidence on all relevant factors related to women’s mental health. From this perspective, public policy including economic policy, socio-cultural and environmental factors, community and social support, stressors and life events, personal behaviour and skills, and availability and access to health services, may all be seen to exercise a role in determining women’s mental health status.

Davar (2008) advocates for the need to theorise psychological distress, hitherto called mental illness, in terms of psychosocial disability. The World Federation of Mental Health (1996) too traced the role of psycho social factors with respect to mental illness among women and argued ‘Psychological distress for women often has social origins. Discrimination against women in employment, education, food distribution, health care and resources for economic development renders them vulnerable to physical and sexual violence, psychiatric disorders and psychological distress’.

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Let us examine few facts on Women and Mental health: Box 3.1 Gender Disparities and Mental health: The Facts (WHO 2020) • Depressive disorders account for close to 41.9% of the disability from neuropsychiatric disorders among women compared to 29.3% among men. • Leading mental health problems of the older adults are depression, organic brain syndromes and dementias. A majority are women. • An estimated 80% of 50 million people affected by violent conflicts, civil wars, disasters and displacement are women and children. • Lifetime prevalence rate of violence against women ranges from 16 to 50%. • At least one in five women suffers rape or attempted rape in their lifetime. The aforesaid data reveals the pattern of psychiatric disorder and psychological distress among women and the gender differentials in the prevalence of mental illness. Symptoms of depression, anxiety and somatic complaints are predominating among women (World Health Organization 2001). Let us examine various psychosocial factors that impact the mental health of women.

Factors Affecting Mental and Emotional Well-Being of Women Women’s concerns with psychological well-being extend across the life cycle and cannot be confined to reproductive functioning. In attempting to differentiate women’s mental health concerns from those of men, it might be argued that they could be defined as including, but not being limited to, conditions, diseases or disorders which are unique to women; occur more commonly in women; have different risk factors for women; or follow a different course in women relative to men (WHO 2000). The psychosocial factors clearly make the women more predisposed to mental disorders due to rapid social changes, gender discrimination, and social exclusion, gender disadvantages like marrying at young age, husband’s substance abuse and domestic violence in addition to socio-economic disadvantages, low income and income inequality, low or subordinate social status and rank and unremitting responsibility for the care of others (Patel and Kleinman 2003). Divorced and widowed women are at slightly elevated risk of mental disorders (Hackett et al. 1999). As argued by Mathew (2016), women often have a tendency towards exaggerated feelings of inadequacy and self-blame. They blame themselves readily for all that goes wrong not only in their lives but also in the lives of their family members—husband, children and parents. It is the cultural expectation which produces such tendencies. All the institutions of our society reinforce this.

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• Social Exclusion and Discrimination Social exclusion is a useful concept for understanding the social experience of people with mental illness. Social exclusion means lack of participation in social activities, diminished opportunity and capacity to participate and being socially isolated. It results in unequal access to resources, capabilities and rights which lead to health in equalities. Mental illness is complexly related with many components of social exclusion like, lack of social networks and underemployment. Exclusion of persons with mental illness contributes to under treatment, social isolation and low help seeking and limited access to care leading to a vicious circle of further exclusion. Discrimination is a behavioural response based on prejudice towards a minority group. Discrimination also appears as unwillingness to help or as active avoidance. Social inequality has damaging consequences for the mental and emotional well-being of women. Throughout their lives, women may be considered ‘at risk’ of developing emotional problems due to a host of social factors like, limited participation in public life, restricted decision making, devaluated role expectations, poverty, violence and sexual abuse. • Lack of Social support Social support refers to the psychological and material resources provided by asocial network to help individuals cope with stress. It can improve motivation level of the individual. Social support involves having a network of family, friends and institutes that help individual to face crisis and provide immediate assistance. There has been an ample amount of evidence showing that social support aids in lowering problems related to one’s mental health. Degree of low acceptability and the negative attitudes of society towards persons labelled ‘mentally ill’ are well known. Social isolation and lack of meaningful life continue to be a problem for persons with mental illness. Strong social support always helps cope with the crisis situation. In stressful times, social support helps people to reduce psychological distress. Social support can simultaneously function as a problem focused and emotion focused coping strategies (Folkman and Lazarus 1991). People with low social support report more subclinical symptoms of depression and anxiety than do people with high social support (Barrera 1986; Cohen and Wills 1985). Social support has long been considered to be having an impact on mental health of women. A study carried out by Coker et al. (2003) suggested that interventions to increase emotional and social support to women victims of violence might reduce the negative consequences of mental and physical health. • Violence and Sexual abuse Violence against women within the family or community includes sexual harassment and abuse, rape, forced prostitution and violence perpetrated or condoned by the state. In a society like ours, which is tradition bound and male dominated, women are confined to domestic servitude; their movements being restricted with minimal autonomy. The imposition of restriction begins in the family of orientation which eventually helps her to adjust passively with the family of procreation. Despite

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the women’s subdued position in the family, they face various types of violence— physical, psychological, sexual and intellectual. The traumatic experiences include those which occur in childhood such as sexual abuse, bullying, body shaming and those which occur in adulthood such as intimate partner violence or sexual coercion (Chandra 2019). According to a report by United Nations, around two-third of married women in India were victims of domestic violence and one incident of violence translated into women losing 7 working days in the country (Kaur and Garg 2008). Furthermore, as many as 70% of married women between the ages of 15 and 49 years are victims of beating, rape or coerced sex (Press Trust of India 2005). The common forms of violence against Indian women include female feticide (selective abortion based on the foetus gender or sex selection of child), domestic violence, dowry death or harassment, mental and physical torture, sexual trafficking and public humiliation. The reproductive roles of women, such as their expected role of bearing children, the consequences of infertility and the failure to produce a male child have been linked to wife-battering and female suicide (Davar 1999; Dennerstein et al. 1993). Violence against women remains a global problem that drastically undermines their mental health resulting in depression, Post-Traumatic Stress Disorder (PTSD), anxiety disorders, personality disorders, eating disorders and emotional suffering (Stotland and Stewart 2001). Mental health sequels to spousal violence are significant and have long-term health implications. Battered women were found to have more depressive symptoms than other women (Campbell and Lewandowski 1997). Furthermore, women who experienced physical or sexual abuse in childhood also experienced ill health with regard to physical functioning and psychological well-being as compared to other women (McCauley et al. 1995). • Poverty Mental disorders have been linked with alienation, dependence and poverty. Women who are poor and those who are less educated are found to be at increased risk of poor mental health. Most of the data shows that working women are paid on average 30–50% less than men, doing the same job and often work without minimum wage protection or benefits, including access to Pension plans, regular schedules and health insurance (Report of United Nations 2000). Moreover, most women work in lower status job. The job responsibilities must be reconciled with family responsibilities which allow little time for rest, relaxation or time out of the house (Desjarlasis et al. 1995). The majority of the world’s undernourished are also women and girl children. Many women have no access to safe drinking water—a fundamental necessity. The task of water collection usually falls to women who are burdened with fuel collection, food preparation and agricultural activities (United Nations 2000). Women living in poverty are disproportionately affected by social exploitation. These women are faced with various types of social, physical and economic hardships which in association with the experience of domestic violence are likely to increase their vulnerability to mental morbidities (Patel et al. 1999). Poorer women are more likely to suffer from adverse life events, to live in stressful conditions, to have fewer

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occupational opportunities and to have chronic illnesses: all of these are recognized risk factors for common mental disorder (Kermode et al. 2007). • Violation of Human Rights There is a severe shortage of accessible and appropriate government services for women with psychosocial or intellectual disabilities and their families. Although women and girls with disabilities are technically included in healthcare, education, rehabilitation and employment schemes that the government provides for all women and children, in reality they often lack meaningful access. There is also a gap in services, particularly gender-sensitive health care, geared towards supporting women and girls with psychosocial or intellectual disabilities in their daily lives. An analysis of the condition of institutional care for women with psychosocial or intellectual disabilities; it was seen that women face a range of abuses, including prolonged detention, unsanitary conditions, neglect, involuntary treatment and violence. Factors such as overcrowding, lack of sanitation and lack of any meaningful activities to keep them engaged within institutions (Human Rights Watch 2014). Presented below are some of the case vignettes based on the experiential insights by the author to augment the aforesaid factors affecting women’s mental health.

Case Vignettes A few case studies narrated here portray the issues of women with mental illness, challenges they face and the ordeals they have undergone in their life. Case-1 Deepa (name changed) when first brought to IHBAS in the month of March 2004, was 33 years old with the history of having twelve years of continuous illness with wandering tendencies, aggressive behaviour and irritability. It was reported by the family that she had lived the traumatic experience of gang rape, that took place twelve years back. At that time, she was studying in her BA-II year. After this incident, she left the home without giving any information to her family. Only seven years back, family members had received a letter written by her that she was in a hospital near Bareilly. Deepa’s father was alive at that time and with his initiative, Deepa was brought back to the family. Her parents also came to know that during this period she had a broken marriage and loss of a child. Deepa had five sisters; four of them were staying in Delhi. After death of her father, 3 years back, she and her mother started staying with 5th sister’s family. Her treatment was not continuing regularly and gradually she stopped taking medicines. When she came to IHBAS, she was fully symptomatic and was admitted by 5th sister and her husband. During hospitalization, Deepa was found to be pregnant. With Deepa’s consent, all sisters were informed about this pregnancy, but none of them showed any interest. Ultimately due to lack of any action taken by the family, her pregnancy progressed

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and she gave birth to a baby on 29 October 2004, at GTB hospital. Immediately, after delivery, GTB hospital discharged DS with her baby. It was difficult for IHBAS treating team to keep the baby with mother in the general ward where other acute patients were staying. Repeated requests were made to the authorities of GTB hospital to keep the baby at their nursery, but they refused expressing their limitations to do so. IHBAS took this matter as challenge and made special arrangement for accommodating DS with the child. A 24-hours lady attendant was appointed for DS and a separate attendant for the baby at the cost of the hospital. Deepa was found to be very caring towards her child. Gradually she had shown significant improvement in her symptomatology. After about one year of her admission, she was ready for discharge. Each and every progress/development about Deepa was informed to her sisters and mother. As mother was too old and dependent on others, she was not able to take any decisions for DS. Home visits were done. Several sessions had been conducted between treating team and sister’s family who had brought her at IHBAS. Despite persistent efforts, the sister and her husband totally refused to take any kind of responsibility of Deepa and her baby. In the due course, it was realized that Deepa’s pregnancy was a result of sexual exploitation by her brother-in-law who was the care-giver of Deepa after her father’s death. Moreover, he had even taken Deepa’s signature for transferring property on his name during her partial recovery period. Key Issues: • Victim of a gang rape. • Issue of pregnancy and MTP consent in acutely symptomatic patient. • Sexual exploitation by the family member. • Rejection by the family with legal guardian being old and disabled. • No clear legal guidelines regarding the ability to take property decisions during partial recovering state with symptoms still persisting. • Homelessness due to mental illness and unsupportive family. • The collaborative efforts of two agencies—Government and NGO (i.e. IHBAS and AAA, respectively) • Rehabilitation difficulties due to relapse and discontinuation of medicines. • Lack of rehabilitation facilities for mentally ill women with dependent children No government or NGO facility was available which could accommodate Deepa with her baby. Ultimately, with the help of Non-government organization, Ashrary Adhikar Abhiyan, the team was able to find a place for her in their shelter home. This was an open shelter home and allowed Deepa an opportunity to work while staying in the shelter. Deepa did comply initially but found the facilities not up to her expectations and the rest of the inmates to be below her standards and gradually started voicing her displeasure to be in the shelter. Soon it was learnt that on number

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of occasions, she had left the shelter without information. Her treatment also became irregular, and as per reports, Deepa was again sexually and physically exploited by unknown men on streets. She even lost her child she had cared so much for and had to live with a major physical disability caused due to a road traffic accident. This was the last information received about her. No one knows her where about but the only silver lining was at least for a brief period it was possible to reintegrate her in the community. Case-2 Rani (name changed) A, a 37-year married Hindu lady, was brought by her brother at the Out Patient Department of IHBAS with complaints of low mood and death wishes. She came to IHBAS in the year 2001 and was diagnosed as a case of bipolar affective disorder. It was reported by her brother that Rani was apparently well till 4 years back. She had to leave her job (as an Anganwadi worker) due to pressures of her in-laws and husband. Since then, she had three episodes. According to brother, her symptoms would subside on taking medicines but in-laws would object her taking medications, and this would result in relapse of the symptoms. Rani’s present condition was diagnosed as depression, and medicines were restarted. Despite continuous medicines for more than six months, no improvement could be observed rather Rani’s complaints were increasing every day. On one such visit treating doctor observed a bruise over right shoulder and swollen face. She explained it as result of fall, but the explanation did not seem satisfactory, so Rani was once again evaluated in detail. After persistent efforts by the doctors ultimately Rani revealed that she was beaten up by her husband and this was not the first time. With reassurance about the confidentiality, she gradually opened up. Rani was married at the age of seventeen in an influential and well to do family. This marriage was arranged by her distant uncle and was considered by all as very fortunate for her. Her father had paid handsome dowry for this marriage. Things were fine after marriage except that Rani found her husband to be of short tempered and sometimes suspicious. With her husband’s influence, Rani soon got job of Anganwadi worker. She enjoyed her work. People in the village also appreciated her dedication and work. But gradually things started going wrong. Her husband’s suspiciousness increased, and now he would suspect her every action. Rani’s going out of the house and talking to neighbours would be seen by her husband suspiciously and would even be abused for it. She tried talking to her mother-in-law about this on few occasions but did not get any response. Her father-in-law too did not pay much attention to her complaints rather reprimanded Rani for same. Even after years of marriage and five children, she was abused and beaten up by her husband on suspicion of her fidelity. No one from family would ever interfere on such occasions. Her children too had witnessed it several times. Rani finally stopped working four years back. Her physical and mental torture however continued. This at times was also reinforced by her in-laws. She left the husband’s place twice and went to her brother’s place. Her father was no more. Mother was dependent on her brother. Though brother was very supportive, Rani did not wish to become burden on her brother. Besides she also wanted to stay with her children. So, with no income or alternative to fall back on, Rani was left with no choice except to come back to her husband and be ill-treated by

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him almost on regular basis. She was not willing to take any legal action against her husband as it would affect her children. One day, when it was intolerable, she went to the local police station for assistance but did not get any response. Her brother also tried to help her through involvement of local panchayat. The local panchayat when informed apparently blamed her for everything. According to Rani, her husband was very influential and was involved in high-level village politics so even the panchayat could not help her. Finding herself in such helpless situation, Rani started blaming herself. She kept telling herself to be prepared to tolerate all abuses and assaults of her husband for the sake of her children. She was not ready to leave her children at any cost. For Rani, only ventilation source was IHBAS treating team. Her visits at IHBAS had been increased in last few months. She expressed several times that after coming to this place she gained confidence in her life. Rani’s husband was called several times by IHBAS team. However, he came only twice. Though it was felt that he too required treatment, it was not possible for the team to convince him or his parents to initiate his treatment. It was though possible to convince him to allow Rani to continue her treatment. The team also managed to make him agree to accompany RA during her visits to hospital, but he never kept his promise. Home visit by the social worker, too, was not of much help. Rani is now not willing to seek legal help one more time. She feels that the fact that she can be with her children is motivating enough for her to survive. Key Issues: • Possibility of mental illness in husband, leading to domestic violence and abuse. • Lack of awareness causing non-acceptance of husband’s illness by the family • Woman’s helplessness to access medical treatment for herself • No help from police or local panchayat despite seeking for it. • No alternative support system available in crisis.

Case-3 Anju (name changed), 35 years, married, a graduate Hindu lady reported with her mother at the OPD of Institute of Human Behaviour and Allied Sciences (IHBAS) with complaints of depressed mood, death wishes, headache, low selfesteem, irritability and anger outburst. She had developed her problems after six years of marriage. In her marital life, verbal and physical abuses were common phenomena. Anju was not permitted to interact with others (neighbours, friends or even her own parents), and she was brought by her mother almost after two years of her problem. She was also blamed by her in-laws for the mental illness and ultimately sent to her parents’ place. No support from husband or in-laws. Even her five years old son was not allowed to meet her. After some recovery, the patient was referred to Delhi State Legal Service Authority (DSLSA) for legal help.

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Key Issues: • Verbal and physical abuse by husband and in-laws. • Blaming for developing mental illness. • Treatment and care done by her own family. • Separation from child due to mental illness.

Discussion It is clear from the case vignettes, that mental illness has multifaceted impact on women. The consequences of mental illness may include physical abuse and abandonment, verbal, economic and physical violence, homelessness, negative Judgment, disregarding, distancing and social isolation. Furthermore, it can also be argued that when a woman becomes mentally ill, services are sought infrequently and late, and she is often blamed for her own illness. The mentally ill women are socially ostracized and abandoned by her husband and her own family. Hence, being a ‘woman’ and being ‘mentally ill’ is a dual curse. Physical violence is found to be common and in significant number of the cases perpetrated by the caregivers. Chronic relapsing course of the illness made these women vulnerable to abuse and maltreatment at the hands of their kin as well as others. The relationship between violence and mental health is multidirectional and complex. For most women, history of violence proceeds mental illness results from the experience of violence. Several studies (Stotland and Stewart 2001; Davar 1999; Dennerstein et al. 1993) found that depression, somatic and PTSD symptoms are higher in those with a history of abuse or sexual coercion. But many of the women did not seem to have acknowledged it as problem or sought any help and in cases where it was asked, they were not taken seriously by the agencies that offer help. It is also observed that sexual abuse and exploitation was a common during the course of mental illness, particularly in the periods of homelessness. For some, this has been one of the precipitating factors for the mental illness. These women appeared to have suffered silently. Few of them also have carried the burden of unwanted pregnancies. Depression, anxiety, psychological distress, sexual violence, domestic violence and escalating rates of substance use affect women to a greater extent than a man across different countries and different settings. Pressures created by their multiple roles, gender discrimination and associated factors of poverty, hunger, malnutrition, overwork, domestic violence and sexual abuse combine to account for women’s poor mental health. There is a positive relationship between the frequency and severity of such social factors and the frequency and severity of mental health problems in women. The high prevalence of sexual violence to which women are exposed and the

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corresponding high rate of Post-Traumatic Stress Disorder (PTSD) following such violence render women the largest single group of people affected by this disorder (World Health Organization 2001). Psychosocial factors also play a role in the treatment of women with mental illness. According to a study from the World Health Organization, there are differences in the way women and men seek and use mental health services. There are also differences in the treatment provided. Women are more likely to be prescribed psychotropic medications than men. Women are reluctant to disclose a history of violent victimization unless physicians ask about it directly (APA 2017). Psychosocial rehabilitation of women with mental illness is also a major challenge. The responsibility of care for the mentally ill women is often left to her own family than to husband or his family. In a study of women with schizophrenia and broken marriages, Thara et al. (2003) found that the stigma of being separated/divorced is often felt more acutely by families and patients than the stigma of having a mental illness. Furthermore, The American Psychiatric Association (2017) has identified key barriers to mental health treatment for women: • Economic barriers • Lack of awareness about mental health issues, treatment options and available services • Stigma associated with mental illness • Lack of time/related support (time off work, child care, transportation) • Lack of appropriate intervention strategies including integration of mental health and primary health care services. With inadequate support and a strong gender bias, the mentally ill women are rarely accepted into the family and are forced to fend for themselves resulting in homelessness. Psychosocial rehabilitation of women recovering from mental illness is a challenge for practitioners. Also, as evident, there is a need for multipronged efforts by a multidisciplinary team of professionals to look into psycho social as well as medical aspects of mental illness.

The Way Forward Changes in gender-related social norms, values and practices can ultimately transform the way society values girls, and improve women’s status. Over time, these changes should result in improved health and increased well-being for men and women. In order to influence these deep-rooted beliefs, however, development programmes seeking to promote gender equality and sexual and reproductive health must start early (Centre for Development and Population Activities 2010).

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To reduce the burden of mental disorders in women, there is need to for socioeconomic empowerment of women by improving access to education and employment opportunities. Education provides awareness of rights and resources, the capability to fight exploitation and economic independence. Education is the key means of empowerment to better women’s mental health. Schools and primary healthcare settings are important sites for mental health promotion. The social, economic and cultural aspects of women’s mental health must be acknowledged and addressed to change the society’s attitudes towards women. There is a need to create community-based structures for providing social support for rehabilitation of women recovering from mental illness. Mathias et al. (2017) emphasise on increasing safe social spaces include building mental health knowledge, increasing opportunity for participation for excluded groups and at macro-levels by facilitating formation of social networks and helping create a receptive environment among diverse ‘boundary partners’ in the community. The emphasis should be given on to promote the formulation and implementation of health policies that address women’s needs and concerns from childhood to old age. There is a need to develop and adopt strategies by the government that will improve the social status of women, remove gender disparities, provide economic and political power and increase awareness of their rights. Multidisciplinary mental healthcare services, social support networks and grassroots organizations all have an important role to promote women’s mental health services. Effective participation of all stakeholders working with women is vital in promoting optimal women’s mental health services and developing appropriate policies. Enhancement of women’s autonomy should play a key role in mental health policy and services. It is essential to ensure that women have a voice and are primarily involved in formulating consensus on their own issues. It is essential to improve the criminal justice response to violence against women. The more fundamental need is to enhance the competence of primary healthcare providers to recognize and treat the mental health consequences of domestic violence, sexual abuse and acute chronic stress in women. Gender discrimination and any type of oppressive practices cannot be removed by legislation alone, but require active participation of all various stakeholders. Professionals in the various disciplines have a clear and responsible role in this (Mathew 2016). It is also required to develop and adopt strategies that will improve the social status of women, remove gender disparities, provide economic and political power, increase awareness of their rights and so on. Although much depends upon the policy makers and planners, but women must also learn to speak for themselves. Women must act as social activists to fight against the social evils, which are responsible for their woes. Women’s anti-alcohol movement in Andhra Pradesh where they destroyed the liquor shops to fight drunkenness of their husbands is a historical landmark. Similar movements to fight prostitution, sexual abuse and domestic violence could be historical leading steps. Education, training and interventions targeting the social and physical environment are very important for addressing women’s mental health. The development of

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policies to protect and promote women’s mental health is extremely crucial. Concerted efforts at social, political economic and legal levels can bring change in the lives of Indian women and contribute to the improvement of the mental health of these women who must learn to speak for themselves.

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Interagency Gender Working Group. (2011). A summary report of new evidence that gender perspectives improve reproductive health outcomes. Washington, DC: Population Reference Bureau. Kaur, R., & Garg, S. (2008). Addressing Domestic Violence Against Women: An unfinished agenda. Indian Journal of Community Medicine, 33(2), 73–76. Kermode, M., et al. (2007). Empowerment of women and mental health promotion: A qualitative study in rural Maharashtra, India. BMC Public Health, 7, 225. Koblinsky, M., Timyan, J., & Gay, J. (1993). The Health of women: A global perspective. Boulder: Westview Press. Liebenwein, S. (2008). Erziehung und soziale Milieus. Wiesbaden: Springer. Lundgren, R., et al. (2013). Whose turn to do the dishes? Transforming gender attitudes and behaviours among very young adolescents in Nepal. Gender & Development, 21(1), 127–145. Taylor and Francis. Mathew S. (2016). Gender issues in psychosocial rehabilitation. Indian Journal of Social Psychiatry, 32, 63–68. Retrieved from http://www.indjsp.org/temp/IndianJSocPsychiatry32163-6437745_ 175257.pdf. Mathias, et al. (2017). Strengthening community mental health competence—A realist informed case study from Dehradun, North India. Health Social Care Community, 1–12. McCauley, J., et al. (1995). The ‘battering syndrome’: Prevalence and clinical characteristics of domestic violence in primary care internal medicine practices. Annals of Internal Medicine, 123, 737–746. Mogge-Grotjahn, H. (2015). Körper, Sexualität und Gender. In M. Wendler & E. Huster (Eds.), Der Körper als Ressource in der Sozialen Arbeit: Grundlegungen zur Selbstwirksamkeitserfahrung und Persönlichkeitsbildung (pp. 141–154). Wiesbaden: Springer. Patel, V., & Kleinman, A. (2003). Poverty and common mental disorders in developing countries. Bulletin of the World Health Organization, 81(8), 609–615. Patel, V., et al. (1999). Women, poverty and common mental disorders in four restructuring societies. Social Science and Medicine, 49, 1461–1471. Press Trust of India. (2005, October 13). Two-third married women victims of domestic violence. Retrieved from http://www.expressindia.com/fullstory.php. Rendtorff, B. (2006). Erziehung und Geschlecht: Eine Einführung. Stuttgart: W. Kohlhammer. Stotland, N. L., & Stewart, D. E. (2001). Psychological aspects of women’s health care: the interface between psychiatry, obstetrics and gynaecology. Washington DC: American Psychiatric Press. Thara, R., Kamath, S., & Kumar, S. (2003). Women with Schizophrenia and broken marriages. International Journal of Social Psychiatry, 49, 233–240. United Nations. (2000). The world’s women 2000: Trends and statistics. Retrieved from https:// unstats.un.org/unsd/demographic/products/indwm/index.htm. World Federation of Mental Health (1996). World mental health day planning kit, 1996. Themewomen and mental health. Alexandria, VI: World Federation of Mental Health Secretariat. World Health Organization. (1998). The world health report, 1998. Executive summary. Geneva. World Health Organization. (2000). Women’s mental health: An evidence based review. Retrieved from https://www.who.int/mental_health/media/en/67.pdf. World Health Organization. (2001). The world health report 2001—mental health: New understanding, new hope. Retrieved from https://www.who.int/whr/2001/en/. World Health Organization. (2020). Gender disparities and mental health: The facts. Retrieved from https://www.who.int/mental_health/prevention/genderwomen/en/.

Chapter 4

Gender Roles in Mental Health: A Stigmatized Perspective M. S. Bhatia and Aparna Goyal

Introduction Mental health is the capacity of individuals within groups and the environment to interact with one another in ways that promote subjective well-being, optimal development, and use of mental abilities (cognitive, affective and relational) and achievement of individual and collective goals consistent with justice (Scanlon et al. 1997, p. 5). It is the embodiment of social, emotional, and spiritual well-being. Mental health provides individuals with the vitality necessary for active living, to achieve goals and to interact with one another in ways that are respectful and just (VicHealth 1999, p. 4). The concept of mental health, over the years, has gained a lot of significance. While earlier it was only looked upon in terms of lunacy or insanity; gradually over the years, people have started relating it with mental well-being and its active significance in day-to-day life. Despite this, there is still a large ‘at risk’ population, for example, persons living in extreme poverty, abandoned women and children, women experiencing domestic violence, persons traumatized by war and violence, refugees and displaced persons, women survivors of sexual abuse, etc. Furthermore, research evidence reflects a strong prevalence of gender differentials within the context of mental health and illness. Let us begin the current chapter by gaining an in-depth understanding of sex and gender and its impact on gender-based norms prevalent in society.

M. S. Bhatia (B) · A. Goyal Department of Psychiatry, University College of Medical Sciences and Guru Teg Bahadur Hospital, Dilshad Garden, Delhi, India e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2020 M. Anand (ed.), Gender and Mental Health, https://doi.org/10.1007/978-981-15-5393-6_4

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Understanding Gender and Gender Norms The sex/gender distinction has always been essential to feminist scholarship, as what the term ‘gender’ uncovered was a vast and intellectually fertile domain. As observed by Simone de Beauvoir, ‘one is not born, but rather becomes, a woman’. Gender and also sex are made through complex social and technical manipulations that naturalize some while abjecting others (Enke 2012). Sex is a system of biological reproduction, a matter of natural fact. Gender, by contrast, is a culturally constructed role. Thus, sex is a matter of nature, gender of nurture. Feminists argue that gender, not sex per se, raises concerns of justice between men and women. They deny that the inequalities and restrictions that go along with a traditional division of labour between the sexes result from the different natures of men and women. What is natural is relatively unalterable (despite the technological advancements). By and large, there is a relative consensus among the Indian feminist scholars with respect to the socio-cultural transmission of gender norms and identities. As noted by Anand (2019a) Gender norms are the sets of rules for what is appropriate masculine and feminine behaviour in a given cultural context. The collections of gender norms are what make up a sex role, a set of expectations about how someone labelled a man or someone labelled a woman should behave. The way in which being feminine or masculine, a woman or a man, becomes an internalized part of the way one thinks about ourselves and engrains one’s gender identity. The concept of gender identity is therefore consistent with an individual approach to gender, focusing on how gender operates from the inside (gender identity) out (Ryle 2015).

Therefore, gender norms and identities are related to ideas of what constitute femininity and masculinity. Gender determines the differential power and control men and women have over the socio-economic determinants of their mental health and lives, their social position, status and treatment in society and their susceptibility and exposure to specific mental health risks. A gendered approach to mental health means distinguishing between biological and social factors while exploring their interactions and being sensitive to how gender inequality affects mental health outcomes (Anand 2016). Gender differences are also significantly observed in the rates of common mental disorders in which women predominate and thus also constitute a serious public health problem. Furthermore, we wish to argue that gender roles also have an impact on an accurate identification and treatment of psychiatric disorders. Common mental disorders like depression, anxiety have a direct relation with psycho social stressors like sexual and domestic violence, substance abuse by the spouse along with factors like gender discrimination, pressures created by shouldering multiple roles, poverty, malnutrition and these indeed are related and account for poor mental health of women. Let us examine the popular discourses on models/perspectives on mental illness with thrust on gender.

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Women’s Mental Health: A Debate on Perspectives There are various discourses that theorize the aetiological factors in causation of mental illness, each with their unique research evidence. While, nature as well as nurture is considered as significant contributors in the context of mental illness, various theorists and practitioners argue that environmental, neurobiological as well as genetic factors are implicated with respect to the origin and prevalence of psychiatric disorders. The biological or pharmacological understanding on mental illness links its prevalence to biological phenomena, such as genetic factors, chemical imbalances and brain abnormalities; and has gained considerable attention and acceptance in recent decades (Wyatt and Midkiff 2006). Evidence from various studies indicates that most psychological disorders do have a genetic component. The biological viewpoint is also considered significant with respect to mental illness as the brain structure and response to stress is different among males and females (Yu 2018; Eagly and Wood 1999). Malhotra and Shah (2015) too postulate that brains of women and men are wired and structured differently in terms of the way they response to stimuli and events. Psychological model thrusts that associative networks are based in the neural substrate but are developed through learning, and rely on theories of conditioning, perception, appraisal, and belief formation, on propositional and implicational encoding, on mental models of the world and internalized schemas of relationships, and so forth (Anand 2018). Psychologists have also proposed a theory with the Freudian viewpoint, where male anatomy and masculinity is the desired goal. Alpha bias proposes that men and women are different and opposite while those with beta bias ignore the gender differences and is in keeping with cognitive/behavioral/humanistic existential theories (Hare-Mustin and Marecek 1988). Gender schema theory has also been proposed on similar lines where gender schema is considered as a cognitive structure that segregates qualities and behaviour into masculine and feminine categories and associations between the categories. Over their life course, men and women start assimilating subsets of such behaviour which corresponds to their schema where girls acquire more of playing with dolls and dressing up and performing domestic chores while boys pick on more on outdoor games and roles to become a bread winner (Rao et al. 2015). Socio-cultural model postulates the significance of socio-cultural factors on mental health in a variety of ways, including predetermining the pattern of specific mental disorders; producing basic personality types, some of which are especially vulnerable to mental illness; producing mental disorders through certain child-rearing practices; perpetuating mental disorders by rewarding it in prestigious roles; producing mental illness through certain stressful roles; affecting mental disorders through the indoctrination of its members with particular kinds of sentiment; affecting the distribution of mental disorders through patterns of breeding; and affecting the distribution of mental illness (Leighton and Hughes 1961). Research has also dwelled into different socio-demographic factors from a gendered lens and found that we are still far behind

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in understanding the exact determinants of how gender effects on mental health. In a study by Klose, being single and unemployed was associated with increased rate of mental disorders in men than in women while higher social class and having children appeared to be protective factors for men only (Klose and Jacobi 2004). The biopsychosocial model developed by Engel (1980) is considered as a means of providing a scientific account of mental disorder that could challenge a reductionist biological account. This model conceptualizes mental disorders as emerging from a human system that has both physical elements (biological nervous system) and psychosocial elements (relationships, family, community and the wider society) (Kinderman 2005). It addresses the biological, social, environmental, psychological and behavioural aspects of mental illness and considers the non-medical determinants of disease in collaboration with the purely biological components (Gehlert and Brownie 2012). The emphasis within the biopsychosocial model is on social and psychological perspectives, and not exclusively on the biological aspects of mental disorder, needs to be given to how, in each case, the elements—bio, psycho and social relate one to another (Anand 2018). In practice, the model has been interpreted as reserving a dominant position for biomedical approaches—with social and psychological factors being acknowledged but nevertheless considered to be mere moderators of the direct causal role of biological processes (Kinderman 2005). Let us further examine the prevalence of psychiatric disorders among women.

Prevalence Rates of Psychiatric Disorders Among Women Epidemiologic and anthropological data points to different patterns and clusters of psychiatric disorders and psychological distress among women as compared to men. The origins of much of the pain and suffering particular to women can be often traced to the social circumstances of lives of women. Socialized to be submissive, tolerant and timid, women often undergo bouts of depression, hopelessness, exhaustion, anger and fear, are overworked, face domestic and civil violence, entrapment and economic dependence. Understanding the sources of ill health for women means understanding how cultural and economic forces interact to undermine their social status. Gender-specific risk factors for common mental disorders that disproportionately affect women include gender-based violence, socio-economic disadvantage, low income and income inequality, low or subordinate social status and rank and unremitting responsibility for the care of others (Anand 2016). Lifetime prevalence rates for any kind of psychological disorder are higher than previously thought, are increasing in recent cohorts and affect nearly half the population. Despite being common, mental illness is underdiagnosed by doctors and less than half of those who meet diagnostic criteria for psychological disorders are identified by doctors. Although there are similar prevalence rates with respect to mental illness among men and women, however, striking differences in their patterns are found across the two sexes. Gender differences have been reported in age of onset of symptoms, frequency of psychotic symptoms, course of these disorders,

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social adjustment and long term outcome. The disability associated with mental illness falls most heavily on those who experience three or more comorbid disorders. Again, women predominate (WHO 2020). Therefore, keeping in mind the impact of socio-cultural factors on mental health, gender becomes an extremely significant factor. There is a need to pay greater attention to gender-specific determinants and mechanisms that promote and protect mental health and foster resilience to stress and adversity. National Mental Health Survey of India by NIMHANS (2016) too reiterates the prevalence of significant gender differentials with regard to different mental disorders. The overall prevalence of mental morbidity has been found to be higher among males (13.9%) than among females (7.5%). While, there is a male predominance in alcohol use disorders (9.1 vs. 0.5%) and for bipolar affective disorder (BPAD) (0.6 vs. 0.4%); Specific mental disorders like mood disorders, neurotic disorders, phobic anxiety disorders, agoraphobia, generalized anxiety disorders and obsessive-compulsive disorders were higher in females. Based on our clinical experience, we observe that during childhood, there is a higher prevalence of conduct disorders and aggressive antisocial behaviours as reported among boys than girls while during the adolescent years, teenage girls are more affected by eating disorders and depression while teenage boys are seen engaging in high risk behaviours, anger outbursts and substance abuse. Suicide attempts are found to be more prevalent among girls though boys are said to ‘complete the suicide’. Furthermore, although severe mental illnesses like Schizophrenia and bipolar disorders do not have gender differences in their prevalence but they do differ in terms of the age of onset, frequency, course, prognosis and outcome of disease. Gender differences occur particularly in the rates of depression, anxiety and somatic complaints. Females do tend to report higher emotional problems, depressive symptoms, anxiety, higher suicide attempts. Depressive disorders account for close to 41.9% of the disability from neuropsychiatric disorders among women compared to 29.3% among men. Unipolar depression which is predicted to second leading cause of burden by 2020 is twice common and more persistent in women (WHO 2020). Women are about twice as likely as are men to develop depression during their lifetime (WHO 2013; Geo et al. 2019; Mirowsky and Catherine 1986; Rosenfield 1989). On the other hand, lifetime prevalence rate for alcohol dependence and antisocial personality disorder more in men (NIMHANS 2016). In the case of developed countries, approximately 1 in 5 men and 1 in 12 women develop alcohol dependence during their lives. Post-partum depression is seen 11% in women, which increases to 26% if only adolescent mothers are considered (Rao and Tandon 2015). A systematic review has estimated that about one in six pregnant women and one in five women who have recently given birth from low- and middleincome countries experience a common mental disorder like anxiety, depression, irritability, mood swings, etc. (Fisher et al. 2012). Among the elderly population though women out run men, Alzheimer’s disease incidence is similar in case of both men as well as men. However, due to increased life expectancy of women, there are more women living with the disease than men. Let us now examine few gender-specific psychiatric disorders.

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Gender-Specific Psychiatric Disorders Apart from common mental disorders like depression, anxiety, somatization and eating disorders which are more commonly seen among females but are also prevalent in either sex, there are certain disorders which can only be seen in female by virtue of their being females. Onset of menarche is a major life event for a girl as that is taken as her setting foot towards adulthood. Though not mentally mature, her body undergoes pubertal changes and barely moving from childhood to adolescent, the growing female child is confused with social dictums where belief that menstruation contaminates the body and makes it unholy. The girls are considered untouchables during the period of menstruation making them feel unworthy, impure, unclean and dirty (Rao et al. 2015). These make them vulnerable to gender-specific psychiatric disorder. The following section dwells into various gender-specific psychiatric disorders commonly prevalent among girls and women: • Premenstrual Dysphoric Disorder (PMDD) PMDD, premenstrual dysphoric disorder, a new entity in Diagnostic and Statistical Manual-5th edition (DSM-5 by American Psychiatric Association 2013), is characterized by irritability, mood swings just before or during menstruation. The symptoms are induced by luteal hormones and are relieved in the follicular phase of the cycle and when hormonal cycling is interrupted. Luteal hormone abnormalities in metabolism or receptors, or because of vulnerabilities in serotonin and vasopressin or prefrontal inhibitory circuits (Protopopescu et al. 2008). Primary role of androgen hormone is also considered due to features of irritability as main symptom, and role of oral contraceptive and SSRIs in its treatment leading to reducing androgen levels (Pinna et al. 2009). It has also been suggested to focus more research on hormonal evidences as the studies have shown effect on mental health in adulthood due to hormonal exposures during gestation (Altemus 2010). • Post-Partum Psychiatric disorders Post-partum period has been linked with increased risk of psychiatric disorders. Postpartum blues, Post-partum depression and post-partum psychosis are more common mental disorders seen in this period. Nosologically, the status of these disorders is still evolving and though not a distinct entity yet, it is used as a specifier as per DSM-IV TR (American Psychiatric Association 2000). Post-partum disorders are seen in 1–2/1000 new mothers within first four weeks of delivery. They range from symptoms of paranoid, grandiose, or bizarre delusions, mood swings, confused thinking, and grossly disorganized behaviour. Post-partum blues is one of the most common but less severe disorder affecting about 50–80% of new mothers (O’Hara 1991). Baby Blues or Maternity Blues as it is also called is characterized by emotional lability with crying spells, irritability and anxiety. Post-partum depression is the more severe form and is characterized by symptoms of a major depressive disorder like pervasive depressed mood, disturbances of sleep and appetite, low energy, anxiety and suicidal ideation along with guilt and mixed feelings about self-adequacy for

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care of her child. Post-partum psychosis is regarded as an emergency as there is high risk of infanticide and suicide. Patient can present with disorganized behaviour, hallucinations and delusions, lability of mood, psychomotor agitation etc. Other disorders seen are post-partum post-traumatic stress disorder characterized by tension, nightmares, flashbacks and autonomic hyperarousal and even can result in tokophobia. Anxiety specific to puerperium is also common in which mothers can have pathological fear of cot death and also have obsessional worry regarding child safety causing nocturnal vigilance, checking on baby breathing leading to sleep deprivation (Rai et al. 2015). • Perimenopausal and Menopausal Disorders Perimenopause is defined by the WHO (1996) as the 2–8 years preceding menopause and the 1–2-year period after final menses, resulting from the loss of follicular activity. Hormonal changes, somatic symptoms and the more frequent occurrence of ‘exit’ or ‘loss’ events for women during this period makes women at higher risk for psychiatric disorders (Rasgon et al. 2005). Perimenopausal depression and anxiety is commonly seen, and studies have also linked to cognitive decline in post-menopausal period. Low education, unemployed, rural background, positive family history for mental illness, late onset of menarche and late perimenopause are associated with higher risk of psychiatric morbidity (Jagtap et al. 2016).

Do the Answers Lie in the Hormones? Tracing the Role of Estrogen Protective effects of estrogen in mental illnesses is extensively studied and researched. Two type of receptors alpha and beta, and three types of estrogen E1, E2 and E3 are identified. Alpha and beta estrogen receptors are mapped widespread in brain, while E2 is the one which is posited to be the cause of protective effects. Life cycle studies have shown that decreased level of estrogen seen during postpartum (Kendell et al. 1987) and menopause (Seeman 1997) are associated with either onset of first episode or relapse of pre-existing illness while increased levels of the same seen during pregnancy confers a lower risk (Kulkarni et al. 2008). Probable hypothesis for estrogen’s neuroprotective and psycho-protective actions can be attributed to antioxidant effects and enhancement of cerebral blood flow and cerebral glucose utilization, genomic mechanisms, causing permanent modification of neural circuits. It is also responsible for modulating dopaminergic, serotonergic, cholinergic and gamma aminobutyric acidergic pathways which are implicated in causation of psychiatric disorders (Dluzen and Horstink 2003). Research also points towards successful use of exogenous estrogen in the treatment of schizophrenia and increased risk in post-menopausal period as the estrogen level falls as well as its possible protective effect in psychotic men (Huber et al. 2005) cement the role of estrogen in mental health.

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Estrogen protective effects have been documented but the data on hormonal changes during these life events is still incomplete. Difficulties in identifying hormone-related syndromes are seen as one where the hormonal changes occur simultaneously or full symptoms may not be clear with only increase in either estrogen or progesterone levels. Circulating hormone levels can differ from levels in specific brain areas or within specific cells because local tissue and cellular enzymes can metabolize steroid hormones to other compounds with distinct activities, such as neurosteroids and effect of oxytocin and inflammatory cytokines complicated by lack of agonists and antagonists which can access the brain, and separate pools of hormone at specific brain sites and in the periphery (Altemus 2010).

Are There Gender-Specific Risk Factors for Psychiatric Disorders? Psychological disorders are connected not only with biological vulnerability, hormonal effects but with gender-based roles, stressors and negative life experiences and events. Some of the women-specific risk factors that affect mental health are genderbased violence, socio-economic disadvantage, low income and income inequality, low or subordinate social status and rank and unremitting responsibility for the care of others. Violence against women has a lifetime prevalence rate from 16 to 50% (WHO 2001). Rape is the fourth most common crime in India against women (Kumar 1993). And the after effects of such an abhorrent crime can lead to serious damage on mental health of the victim. Exposure to sexual violence along with consequent post-traumatic stress disorder (PTSD) render women the largest single group of people affected by this disorder. Gender affects the treatment protocols too. Female are diagnosed more with depression and are prescribed mood-altering drugs earlier than males. Women are also found to be reluctant to disclose a history of violent victimization unless physicians ask about it explicitly. Primigravida, unmarried mother, complicated delivery, past history of psychotic illness, anxiety, depression, positive family history for mental illness, previous episode of post-partum disorder, vulnerable personality traits, low income, birth of a daughter when a son was desired, relationship difficulties with spouse and in laws, adverse life events during pregnancy and lack of physical help are all risk factors for the onset of post-partum depression (Sharma and Mazmanian 2003). Gender-based risk factors such as the bias against female babies; role restrictions regarding housework and infant care; and excessive unpaid workloads; especially in multigenerational households in which a daughter-in-law has little autonomy, and gender-based violence also are some other gender-based risk factors that affect women mental health (Fisher et al. 2012).

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Gendering the Stigma of Mental Illness Mental illness has always been linked to stigma where those with psychiatric disorder were considered insane and lunatic and were shunned from the society. Both men and women experience considerably high level of associated stigma and discrimination due to their mental (Lauber and Rössler 2007). However, women in comparison to men experience significantly greater level of internalized stigma, especially in domains of discrimination experience and social withdrawal (Khan et al. 2015). Stigma is perceived as a negative attitude and incorporates three main elements, namely prejudicial attitudes, insufficient knowledge and discriminatory behaviour (Thornicroft et al. 2007). Stigma of mental illness is the negative attitude (based on prejudice and misinformation) that is triggered by a marker of illness. Stigma is construed as “a ‘mark’ of social disgrace”, and therefore, it is not surprising that those with mental illness are treated as socially disqualified and are kept away from mainstream social life. The presence of stigma starts a vicious circle that leads to discrimination in all walks of life, decreasing self-esteem and self-confidence, a low treatment effect or high probability of relapse for those in remission, and thus to a reinforcement of the negative attitudes and discrimination (Sartorius and Schulze 2005). The fear as well as experience of stigma in case of women therefore often leads to non-disclosure of their psychiatric illnesses, and shying away from treatment facilities; thus, potentially leading to poorer outcomes as compared to men with psychiatric disorders. Thus, stigma can be construed as an impediment to recovery among women with psychiatric disorders (Sarkar and Punnoose 2016). Living with mental illness poses multifarious challenges to the women who experience it. They not only face the physiological symptoms but also have to battle various odds in their larger societal relationships as well as in their intimate relationships (Anand 2019b). Sharma and Pathak (2015) remarked about how women health’s can only be catered by the specialty of obstetrics and gynecology in medical sciences and thus their mental health too is seen only in the context of reproductive health while ignoring other areas like psychopharmacology, psychosocial determinants of mental health, and legal issues. When women become mentally ill, they are not only socially ostracized but also blamed for the illness. It is quoted as a triple tragedy where married women with severe mental illness are seen struggling with the so-called Indian Paradox which is fighting for their conjugal rights rather than for separation or divorce (Sharma et al. 2013). Thara and Srinivasan (1997) reported that married female especially with no children had poor marital outcome than males possibly as to Indian female are reared with more acceptance towards their counterpart as compared to otherwise. Also, whereas women are required to be the primary care givers if their husbands were mentally ill, it is themselves who still need to carry on with the role of care giving to the family despite their problems (Malhotra and Shah 2015). In a recent study by Boge et al. (2018) in five metropolitan Indian cities, it was found that there was higher perceived stigma towards mental illness among women. This was attributed to culturally coined dispositions on women through gender roles

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and negative attitudes. Though over the years the role of women in society has changed, but still the duty of domestic chores lies mostly on the females. In India, females are considered to be homemakers and though this role is equally important, fear of failure and caregiver burden if affected by illness constitute a psychological distress (Boge et al. 2018). Another study by Liu et al. (2011) reported that marital and interpersonal problems constitute one of the most common causes for attempted suicide among Indian women. Fear of social marginalization, rejection, abandonment and domestic violence if stigmatized as a person with mental illness was proposed as a cause of higher levels of internalized stigma by Indian women even when there is no immediate rejection or discrimination (Soman et al. 2017). Surprisingly, the stigma not only extends in term of illness but also biased in treating physician. Only women professionals are expected to work in this area as it is considered as ‘more of a woman’s domain’. Male professionals have been reported to less engage themselves in sensitive areas like domestic violence, rape, dowry, etc. (Sharma and Pathak 2015). An examination of institution-based treatment of psychiatric disorders, most government psychiatric hospitals and departments operate in what Addhlakha (2008) calls an ‘acute model of management”, in which practitioners’ “clinical work demand an instrumental stance”, and an almost “impossible mandate requir[ing] that they discharge patients quickly, and yet treat them adequately”. Furthermore, people in many mental hospitals are restrained with metal shackles, confined in caged beds, deprived of clothing, decent bedding, clean water or proper toilet facilities and are subject to abuse and neglect. An analysis of the condition of institutional care for women with psychosocial or intellectual disabilities; reflects that women face a range of abuses, including prolonged detention, unsanitary conditions, neglect, involuntary treatment and violence (Human Rights Watch 2014). Furthermore, there is also a biased opinion among those providing health care. Up to 20% of those attending primary health care in developing countries suffer from anxiety and/or depressive disorders. In most centres, these patients are not recognized either due to inadequacy of the training among healthcare workers or due to their prejudices over those with mental illness and therefore not treated. Communication between health workers and women with mental illnesses is extremely authoritarian, thereby making the disclosure by woman regarding her psychological and emotional distress even more difficult, and often stigmatized (Kumar et al. 2013). Interestingly, while women have been subjected to these abhorrent crimes no one questions the dependency of male on their female household member for their daily domestic needs like cooking, washing, child care, etc. It has been postulated that this dependency if modified or even shared can also lead to decreased risk of domestic violence, thereby improving the overall psychological environment at home and thus improving the mental health of the entire family.

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The Road Ahead: Eclectic Strategies for Prophylaxis and Reforms We, as physicians, proceed with caution when a female is going through puberty, having her menstrual cycle or is in puerperium or undergoing menopause. Keeping in mind the biopsychosocial perspective, we realize that all the phases in a life cycle of female are marked with unique risks for mental illness. Whether an illness is biological or more of psychosocial effect, no one is wiser. We can probably attribute it to a cumulative cascading effect rather than relating it to any one factor or to the individual himself/herself. Biologically, hormonal abnormalities may arise at the synthesis, metabolism or receptor level affecting the pathways from gene to behaviour including epigenetic modification expression and plasticity of neurons, synapses and neural networks but still can form organized, identifiable psychiatric syndromes (Altemus 2010). Furthermore, WHO reports that research has predicted three main protective factors in women against development of mental problems, i.e. having autonomy, access to material resources and psychological support from the ‘near and dear ones’. World Health Organization (2002) thrusts on the prevention of mental disorders as a public health priority; multiple determinants of mental disorders; the need for multipronged and multidisciplinary effort, increased thrust on effective prevention to reduce the risk of mental disorders; relying on available evidence during implementation; creating public awareness on successful programmes and policies, and; expansion of knowledge of evidence for effectiveness. It targets to build evidence on the prevalence and causes of mental health problems among women as well as on mediating and protective factors which can lead to formulation of effective laws and policies to enhance the cultural, political and legal standpoint of women. These indeed can go a long way in providing autonomy to women. It recommends to enhance the competence of primary healthcare providers to recognize and treat mental health consequences of domestic violence, sexual abuse, and acute and chronic stress in women. Furthermore, the following are suggested to improve the mental health of women: • Communication patterns between the health workers and clients need to be improved, and they should be trained better in not only recognizing but also in the holistic approach without stigmatic look. Women should be able to not only have easy access to mental health care but should be able to freely discuss their issues without any judgment from the caregiver or society. • Efforts may be targeted to improve the mental healthcare system with a multidisciplinary approach of pharmacotherapy along with non-pharmacological approaches and help from various self-help and other support groups. • Prevention at primary level by integration of biological and psychosocial factors which can help in reducing stigma and increasing awareness among the public can go a long way in reduction of mental illness. • Better economic and social policies targeting specifically the women’s empowerment. There are reports that economic and social policies can cause sudden

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changes in income and employment can significantly increase gender inequality and the rate of common mental disorders. In a study in England (Fink et al. 2015), it was reported that girls suffer more from stressors, had higher emotional and psychological problems and use rumination for coping as a result of economic and financial crisis. Hence, these policies need to be drafted with care so as not to disturb the balance. Investing in education of women, especially in a developing country like India, where female education is still not a priority would help in improving mental health. The World Bank’s 1993 development reports it to be a single most important determinant of their and their children health. It will also make them less vulnerable to violence as well as the ill effects of economic and financial dependence on their otherwise absent spouses due to substance abuse. The Constitution of India provides women the fundamental right to equality and the right not to be discriminated against on grounds of religion, caste and sex. Special provision in Article 15 (3) in our Constitution favours women by enacting provisions so as to ameliorate their social, economic and political condition and to accord them parity. But sadly, we are dishonouring our own constitution by subjecting them to violence, disgrace, discriminating them by denying them education, autonomy and decision making and labelling them only as a child bearer and caregiver which is again a no small feat. There is a strong obligation in the part of society as a whole to take steps for empowerment of women. The gap between theory and practice which needs to be reduced. Legal provisions are in place for violence but again the reality of its implementation is far from proposition. Laws should be implemented practically and should be enforced strictly so as to make women in our society feel safe and protected. In the year 2017, WHO had focused on mental health at work place as its annual theme for the World Mental Health Day. Inequity and partial behaviour have been noticed, especially in the context of gender. Female are usually given clerical or secretarial job and males do not take it easy while taking orders from a female superior. Women had to fight to get better jobs even with their education and credentials there are very few females who are at the top of the chain. These needs to be revised and they should be given better and suitable job opportunity.

Conclusion Gender and mental health have emerged as an important discourse as gender determines the differential power and control men and women have over the socioeconomic determinants of their mental health and lives, their social position, status and treatment in society and their susceptibility and exposure to specific mental health risks. There is also a severe shortage of accessible and appropriate government services for women with psychosocial or intellectual disabilities and their families (Anand 2019b). Changes in gender-related social norms, values and practices can

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ultimately transform the way society values girls and improve women’s status. Over time, these changes should result in improved health and increased well-being for men and women (Lundgren 2013). Adoption of a strengths-based perspective can further aid in the development of a sense of personal control (agency), and sustaining their motivation towards treatment of women with mental illness and developing their psychosocial skills to override the stigma and discrimination. There is a need to deal with stigma around mental illness in general, and with respect to women in particular. Changing beliefs and behaviours has always been difficult and cannot be done quickly. There is need for a vision for the development of community-based and community-intensive mental health programme that is broadbased and inclusive of all the needs of all the people (Murthy 2004). The thrust on de-institutionalization and rehabilitation of those suffering from mental disorders, especially women and children, may be taken up at the mass level through creative and innovative strategies (Anand 2016).

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O’Hara, M. W. (1991). Postpartum mental disorders. In N. Droegemeuller & J. Sciarra (Eds.), Gynecology and obstetrics (pp. 1–13). Philadelphia, PA: JB Lippincott. Pinna, G., Costa, E., & Guidotti, A. (2009). SSRIs act as selective brain steroidogenic stimulants (SBSSs) at low doses that are inactive on 5-HT reuptake. Current Opinion in Pharmacology, 9, 24–30. Protopopescu, X., Teuscher, O., Pan, H., et al. (2008). Toward a functional neuroanatomy of premenstrual dysphoric disorder. Journal of Affective Disorders, 108, 87–94. Rai, S., Pathak, A., & Sharma, I. (2015). Postpartum psychiatric disorders: Early diagnosis and management. Indian Journal of Psychiatry, 57(Suppl 2), S216–S221. Rao, G. P., Vidya, K. L., & Sriramya, V. (2015). The Indian “girl” psychology: A perspective. Indian Journal of Psychiatry, 57(Suppl 2), S212–S215. Rao, T. S. S., & Tandon, A. (2015). Women and mental health: Bridging the gap. Indian Journal of Psychiatry, 57(Suppl 2), S199–S200. https://doi.org/10.4103/0019-5545.161477. Rasgon, N., Shelton, S., & Halbreich, U. (2005). Perimenopausal mental disorders: Epidemiology and phenomenology. CNS Spectrum, 10, 471–478. Rosenfield, S. (1989). The effects of women’s employment: Personal control and sex differences in mental health. Journal of Health and Social Behaviour, 25, 14–23. Ryle, R. (2015). Questioning gender: A sociological exploration. Thousand Oaks, CA: Sage Publications. Sarkar, S., & Punnoose, V. P. (2016). Stigma toward psychiatric disorders: What can we do about it? Indian Journal of Social Psychiatry, 32, 81–82. Sartorius, N., & Schulze, H. (2005). Reducing the stigma of mental illness: A report from a global programme of the World Psychiatric Association. United Kingdom: Cambridge University Press. Scanlon, K., Williams, M., & Raphael, B. (1997). Mental health promotion in NSW: Conceptual framework for developing initiatives. Sydney, Australia: NSW Health Department. Seeman, M. V. (1997). Psychopathology in women and men: focus on female hormones. American Journal of Psychiatry, 154(12), 1641–1647. Sharma, I., & Pathak, A. (2015). Women mental health in India. Indian Journal of Psychiatry, 57(Suppl 2), S201–S204. Sharma, I., Pandit, B., Pathak, A., et al. (2013). Hinduism, marriage and mental illness. Indian Journal of Psychiatry, 55(Suppl 2), S243–S249. Sharma, V., & Mazmanian, D. (2003). Sleep loss and postpartum psychosis. Bipolar Disorders, 5, 98–105. Soman, S., Bhat, S. M., Latha, K. S., et al. (2017). Do life events and social support vary across depressive disorders? Indian Journal of Psychological Medicine, 39, 316–322. Thara, R., & Srinivasan, T. N. (1997). Outcome of marriage in schizophrenia. Social Psychiatry and Psychiatric Epidemiology, 32, 416–420. Thornicroft, G., Rose, D., Kassam, A., et al. (2007). Stigma: Ignorance, prejudice or discrimination? British Journal of Psychiatry, 190, 192–193. VicHealth. (1999). Mental health promotion plan, 1999–2002. Victoria. Australia: Victorian Health Promotion Foundation. Retrieved from www.vichealth.vic.gov.au. World Health Organization. (1996). Research on the menopause in the 1990s (Report of a WHO Scientific Group), WHO Technical Report Series, 886. Geneva: World Health Organization. World Health Organization. (2001). Gender and women’s mental health. Gender disparities and mental health: The Facts. Geneva: World Health Organization. Available from: https://www.who. int/mental_health/prevention/genderwomen/en/. Accessed on June 2, 2019. World Health Organization. (2002). Prevention and promotion in mental health. Geneva, WHO. World Health Organization. (2013). Department of mental health and substance dependence. Gender Disparities in Mental Health. Retrieved from https://www.who.int/mental_health/media/en/242. pdf. World Health Organization. (2020). Gender in women’s mental health. Retrieved from https://www. who.int/mental_health/prevention/genderwomen/en/.

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Wyatt, W. J., & Midkiff, D. M. (2006). Biological psychiatry: A practice in search of a science. Behaviour and Social Issues, 15, 132–151. Retrieved from http://dx.doi.org/10.5210/bsi. v15i2.372. Yu, S. (2018). Uncovering the hidden impacts of inequality on mental health: A global study. Translational Psychiatry, 8(1), 98.

Chapter 5

Understanding and Locating Mental Health in a Cross-Cultural Context: Indigenous Community Perspectives Malathi Adusumalli

Introduction I begin this article with the conceptualization of mental health provided by WHO. The World Health Organization defines mental health as ‘a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community’ (WHO 2018). While this speaks of the context in terms of the latter part, it does not exclude the ideas of privileging one community over another of ‘having knowledge, hence the power to ‘categorize, subject to treatment conditions’. The power of certain communities ‘therapeutic’ to decide on the criterion of such categorization associated with a pharmaceutical world to decide the ‘treatment’ and also declare that someone is ‘functional’ to be going back to the society. While the ‘community’ decision is respected and acknowledged by the definition here, it is perhaps the truth that that community is indeed powerless in talking about their ideas of health, encompassing mental health, when these are relegated from a particular perspective as ‘traditional and outdated’. There is a certain ‘ethno-centrism’ practiced by therapeutic communities, just as health and illness are again viewed from another ethno centric view point of communities (Cox and Webb 2015). Townsend (1979) speaks of the similarity between popular and professional conceptions of mental illness that share specific traits with ethnic stereotypes. He finds that they are: (1) exaggerated and serve to erect a qualitative boundary where none objectively exists; (2) maintained through selective perception, rationalization and sanctions; (3) they help to erect the ‘thresholds’, i.e. the criteria, for crossing or re-crossing the boundary; (4) they serve to define relations, including those of power, between groups; (5) because they perform these important cognitive and conative functions, they persist despite a flow of personnel M. Adusumalli (B) Department of Social Work, University of Delhi, New Delhi, India e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2020 M. Anand (ed.), Gender and Mental Health, https://doi.org/10.1007/978-981-15-5393-6_5

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across them and despite repeated demonstrations of their inaccuracy. They cannot be expected to change until the actual relations between groups change. While this definition indicates that mere absence of mental disorder need not mean the presence of good mental health, it also could be interpreted to mean that persons suffering from mental disorder can also attain some reasonable level of well-being, managing their life’s stresses and contributing their society. Also ‘the social determinants of the context in terms of power and privilege, poverty-induced stressful physical, social and emotional life, loss of political freedoms, ability, disability, socially marked low status do play a role in shaping mental health conceptualizations’, which have not been emphasized (WHO and Caloste Gulbenkian Foundation 2014, p. 12). This brings us to the context, that White and Marsella (1982) emphasize, on the significance of cultural conceptions of mental health in their book ‘Cultural Conceptions of Mental Health and Therapy. Culture, Illness, and Healing. According to them, ‘cultural conceptions of mental health’ refers to ‘common sense’ knowledge which is used to interpret social and medical experience, and which plays an important role in shaping both professional and ‘everyday’ views of mental disorder’. Thus, this is an ‘interpretive enterprise, based on the ‘social construction of ill health and social behaviour located in particular cultures as standard and reference. They emphasize on conceptualizing mental health as culturally ordered symbolic systems. They speak of the need to research the symbolic and cognitive organization of common sense understandings about mental disorder which give illness experience cultural meaning and social significance. Thus, the universality or cultural specificity of mental disorders could be understood, making significant contribution to human knowledge on this as well as contributing to human well-being, through understanding and treating mental disorders. Understanding cultures thus becomes significant in conceptualizing mental health (Gopalkrishnan 2018) articulates this very well when he deconstructs the concept of culture. As per him disciplinary contexts become the guiding poles for understanding culture, it is broadly identified to signify a set of values that the ‘members of a given group hold and includes the norms they follow and the material goods that they create social construct) belong and all of which contribute to a person’s view of themselves’. Further it is needed to be seen as dynamic as there are ‘broader contexts of social norms and social issues’ like social and political environment and even the natural environment that has significant impacts on health and well-being. As he points out Much of the theory and practice of mental health, including psychiatry and mainstream psychology, have emerged from Western cultural traditions and Western understandings of the human condition. Notions of Cartesian dualism of body and mind, positivism, and reductionism have been central to the development of mainstream mental health systems as they are widely implemented today (8, 9). While these relatively monocultural understandings of mental health have provided powerful conceptual tools and frameworks for the alleviation of mental distress in many settings, they have also been very problematic when applied to the context of non-Western cultures without consideration of the complexity that working across cultures brings with it (10, 11) (Gopalkrishnan 2018, p. 1–2).

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Diverse notions of Mental Health across cultures Speaking of cultural influences, Lee and Kirmayer (2019) articulate the ‘location specific’ interpretation of what is ‘healing and psychotherapy’. These would include such elements as ‘signs of ‘illness and affliction and symbols of transformation’ with processes of healing that could go beyond the ‘local ontological and explanatory model’. The central role of self in the efficacy of this transformation has been highlighted. They point out the significance of culture in giving meaning to the concept of self. Hence, this would mean the veracity of universal applicability of Western models of psychotherapy, developed in their own cultural contexts which are based on individualistic view of self in their society. They speak of Dang Ki healing in Singapore, establish that such healing processes highlight the close bonds between the clients, healers, community and their local deities. Such a reciprocal and interdependent healing process, they emphasize, has ‘transformational’ effects, for all the above, in stark contrast to the individualistic focus of most Western psychotherapies. Despite the emphasis on culture-specific treatment approaches, the Global Mental Health movement and project speaks in terms of ‘treatment gaps’, with respect to dealing with mental health issues, in ‘Western centric’ treatment facilities. There are apparently no questions asked regarding the applicability of ‘diagnostics and treatments of Western psychiatry’ in cultural contexts other than their own (Kirmayer and Pedersen 2014; Ecks 2016). Kirmayer and Pedersen (2014) call for relook at the GMH movement for refining international classification systems’ and for recognizing the folk approaches of health and healing, particularly the local ’idioms of distress’ local modes of coping, resilience and recovery’. They call for the use of multisectoral, cross-cultural and transdisciplinary approaches’ which can provide impetus to global mental health agenda that is ‘more inclusive, participatory and responsive to local realities and perspectives’ (p. 771). The universality of ‘evidence-based treatments is thus questioned (Ecks 2016). I have long been puzzled by the stark incongruences between global mental health policies and local realities. GMH is driven by calculations of psychiatric treatment gaps, but on the ground these gaps look very different than they are imagined in Geneva. For example, GMH assumes a massive treatment gap in the treatment of mental disorders in India, but never stops to ask why there are illnesses, is also many decades old (Ecks 2016, p. 805).

In their editorial to the issue of Indian Journal of Social Psychiatry, 2017, Vol. 33, the editorial by Sarkkar and Punnose (2017) speaks of the importance of cultural diversity to be taken into account for the understanding, diagnosis and treatment of mental disorders. They also speak of culture bound syndromes that are specific to cultures. They feel that cultural understanding can facilitate psycho-education processes. They also emphasize that culture can play a role in the acceptance of what is a desirable level of treatment. They speak of the need for culturally competent and culturally sensitive services, keeping with the view the ‘The current paradigm of offering autonomy to the patient needs’. They also caution against using universal frameworks for explanatory models and treatment processes.

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M. Adusumalli A “one size fits all” approach is unlikely to work in the present fast-paced world with diverse cultures mingling together. Rather, respect for the choices based on cultural proclivities and using culturally endorsed social supports may help distressed individuals in their recovery (p. 286).

In conclusion, they call for mental health professionals to ‘delve deeper into how cultural diversity impacts the presentation, remediation and prognostication of mental illnesses’. They further urge for collaborative efforts to understanding the ‘culture-based needs of the treatment-seeking individuals and enforce policies that do not exclude patients based on specific cultural affiliations’ (p. 286). Cultural diversity impacts on how health and illness are perceived and also accordingly the health-seeking behaviour. Scholars (Hechanova and Waeldle 2017) have identified five key elements that can serve as a guiding framework to understand cultural and mental health linkages in disaster contexts in South Asia. First is that symptoms of health or ill health are connected to emotional expressions that are culture bound. Excessive display of happiness, fear and anger seem to be used as identity markers. But ‘emotional display’ is culture bound. Thus, what expressions in the specific circumstances are considered problematic are fundamentally situated in cultures. That specific cultures are concerned with the idea of ‘shame’, which is present in South Asian contexts which determines the health-seeking behaviour. Concept of shame becomes significant in collectivistic societies. Third aspect is the power differential between the therapeutic community and the clients. The fourth aspect is the nature of collectivistic society, which has implications for support to resilience and coping. The fifth factor is spirituality and religion, providing both explanatory frameworks and suggesting coping. According to WHO (2019) paper on Gender and Mental Health, there is certainly a negative tilt towards women bearing the mental ill health burden. In identifying the gender concerns underlying women’s susceptibility and morbidity, WHO (2019) identifies some of the underlying causes and locates them in the unequal gender relations, power and autonomy, that significantly, influences the social determinants of health and well-being, including mental health. It highlights the need to focus on the ‘mechanisms that promote and protect mental health and foster resilience to stress and adversity’ to make meaningful difference. Gender determines the differential power and control men and women have over the socioeconomic determinants of their mental health and lives, their social position, status and treatment in society and their susceptibility and exposure to specific mental health risks (p. 1).

WHO (2019) also identifies three key factors identified by research, which are highly consistent in promoting mental health of women: having sufficient autonomy to exercise some control in response to severe events; access to some material resources that allow the possibility of making choices in the face of severe events; psychological support from family, friends, or health providers is powerfully protective. This brings me to the discussion on cultural aspects of shaping one’ health and mental health. Cultures have been broadly treated as pan phenomenon in the literature. In mental health across diverse cultural settings, we are broadly referring to

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South Asian Culture, Indian Culture, Chinese culture, and Western culture. These sweeping attempts to speak of cultural conditions and identifies it as one universal category is reflected when we desire to speak of indigenous concepts of health and well-being. Thus, when we speak of India, we generally tend to speak of Ayurveda mostly and to some extent later add the Unani and Siddha systems. However, the cultural diversity and nuances of cultural conditions that shape health and well-being across indigenous communities hardly become focal point. As articulated by (Patel 2001). Another major anomaly is that whereas Western societies are considered ‘multicultural’ so that studies need to be conducted for different ethnic groups to ensure findings are ‘culturally correct’, non-industrialized societies are not offered the same privilege. It is common to see studies from vast, and hugely diverse, countries such as India or China being used to suggest that the findings are representative of the culture of the entire nation. Such naive assumptions have greatly limited the value of cross-cultural studies where the choice of country settings is used as a means of ensuring representativeness of cultural diversity (p. 34) It is also significant that in such communities, the social determinants may not be deleterious to gender equality. The women may have sufficient autonomy compared to the mainstream society. Thus, they may experience good health and mental health. Also, certain ‘cultural expressions’ practiced by them may be seen as ‘irrational’ with’ rationality frameworks arising from other ‘cultural perspectives’, which otherwise are vested with ‘social power’ and reverence, in their own cultures. As argued by Kitayama et al. (1997), the ‘metatheoretical commitment to the Cartesian-like split between culture and the psyche may hinder the understanding the ‘sociocultural nature and origins of many social psychological processes’. I would now look at the notions of health and well-being among the two indigenous communities of Jad Bhotiyas and Chenchus. The former resides in the state of Uttarakhand, and the latter resides in the state of Andhra Pradesh and Telangana’. I argue that health and mental health are to be seen as ‘cultural expressions’ of the two communities.

Notions of Heath and Healing among Jad Bhotiya Community My personal engagement with this community came about in 2013 after the massive disaster that struck Uttarakhand, where my research was on the impacts of the disaster affected communities of the upla Taknore villages close to Gangotri, in the Bhatwari Block of Uttarkashi district. Bagori village, where this community lives was one of the eight villages included. While the picture of devastating floods was a story with Kedarnath as the focus, with the stranded tourists as the major rescue operation with mobilization across national and global levels, the picture of village communities nestling in the hill ranges was quite forgotten. Jad Bhotiyas in Bagori village were

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devastated by the incessant rain that swelled up the local streams, and also cut them off from the district HQ at Uttarkashi and Block HQ at Bhatwari. The untold misery suffered in the devastation caused by Purkha Nala, which joined the Bhagirathi, has shaken the people of Bagori, Channa (2013) in her illuminative book on the ‘Inner and Outer selves: Cosmology, gender and Ecology at the Himalayan Borders’, speaks of the powerful men in this community. When this powerful man wept, while showing the destruction caused by the Purkha Nala, mountain stream that joins Bhagirathi located towards the back of the village, I could see the close interconnections with the natural life. The symbolism of these ‘nalas’, the forests, and the ‘wild around them, could only be slowly understood. Working with this community on Forest Rights Act, brought close bonding with the community, that led me to be part of their ‘Panoh’ festival. The ceremonies and dancing revealed ‘possession’ as one of the ‘acts’. Some women began to dance and sway in rhythmic fashion, while all others viewed them with reverence. These women were given grains that they kept throwing. Being an outsider, I had merely observed, but did not question. My training in psychology and my own personal belief system, would dismiss them as ‘irrational’. Later I came to know about them acting as ‘mediums’ to express desires, of the ‘spirits’. On another occasion, I similarly observed another woman in a wedding party, displaying possession in one of the Assiganga villagers, where she was accusing a man of not returning the money taken from her family. The man was respectfully bending and the woman was being given grains to throw in the air, just like in the village Bagori. From the diagnostic systems we (trained psychotherapists use), this may be classified as a disorder. However, for the communities this may be perfectly natural acts, in line with their cosmology. I would like to draw from Channa (2013)’s work to show their explanatory frameworks, situated in their cultural milieu. Channa elucidates that the Jads do not consider themselves separate from nature, including ‘spirits, gods and goddesses. The concept of a non-dualistic universe and the continuity of life and living are the main anchors for their ‘acts of living’, including all that they do for living their way of life. Thus, the ‘supernatural realm’ is considered to co-exist with the human social world. While the forest is considered wild, there is a continuum from the social world. The spatial boundaries of the village and the jungle are perceived not as dichotomy of the social and the wild, but as the realm of different categories of beings. The cosmological world encompasses both the village and the wild, divided between women and men respectively (Channa 2013, p. 133)

Further, there is no concept of a separate world of dead, or heaven or hell. Thus, the dead are not seen physically, but have a ‘presence’ in terms of their perceived presence. They continue to influence the living. The Jads believe in ‘harmonious coexistence with the world inhabited by the people and the world of the supernatural beings’ (p. 133). There is no closed sacred space. The space they live consists of both sacred and secular spaces, ‘the familiar and the un familiar’. The familiar space includes those with whom they interact, marry, trade and converse. This cosmology

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of the Jads thus helps them to conceive the realm of the supernatural not as fractured form that of the natural and human world, but well integrated into their rituals and festivals, of their kuldevtas (lineage guardians), and their village deity, Me Parang. For the Jads their glah (Gods) like their lahne (ghosts and demons) are active members of their society. They interact with them on a day to day basis. They communicate and converse and express their emotions regularly like all other members of the household and the village. This communication is through dreams, omens, and most frequently, possession of a medium. In fact almost all Jad deities have a fixed medium through which they express themselves. The mediums are both humans and objects such as drum a palanquin or a weapon (p. 139)

Channa also points out the relative autonomy of the Jad women in ‘managing the social world’. The wild in the forests is the domain of a man’s world, to which they take their ‘Lakshmi’ (goddess of wealth), the flock of sheep. The village world, the social relations are entirely maintained by the women. Thus, women have a sense of autonomy vastly different from that experienced by the other ‘pahar’ (hill) women. As Kitayama et al. (1997) suggest a collective constructionist theory of the self in which ‘many psychological tendencies and processes simultaneously result from and support a collective process through which the views of the self are inscribed and embodied in the very ways in which social acts and situations are defined and experienced in each cultural context’ (p. 1247). The possession rituals are also to be seen in this light. Acting as ‘medium’ is done by them in a manner of treating this as an ‘act of performance’, as part of their festivals. Sometimes someone may seek their help, hence such special ceremonies are held to find out the reason for some or other distress. There is no distinction of mental health as separate category. Illness is related to commission of errors, inadvertently, that is there is a ‘dosha’ (a mistake). These need someone to find out why this dosha or offence has occurred. Accordingly, the ones who appear possessed are seen to have such powers of revealing. Once the cause of distress is known, as located in the offence to a particular glah (god), or lahne (ghosts or demons), then the medium will call on the particular glah or lahne to see what the remedy could be. Sometimes the diviner is able to tell directly the nature of the mistake and the remedy, but more often than not, the diviner merely diagnoses which supernatural being glah or lahne, the sufferer has offended. Thereafter resort is taken to a medium, who is able to summon the particular glah or lahne, to tell what the offence was and what remedy should be taken. Sometimes a third specialist is required to arrange for the recourse that may be in the form of an elaborate. ritual or otherwise, the person might follow some patent method of dealing with that particular supernatural being (p. 142)

Another concept is the ‘evil eye’, spirits from the dead affecting them, and the wrath of their village deity, Me Parang. Every such identified cause for ill health and ill being is to treated with appeasing rituals that can calm them, thus helping to get back to their healthy status. The community can also identify an authentic vs sham possession. Further in the egalitarian individualistic ‘spirit associations’ do not give importance to the medium as such (Channa 2013, p. 156).

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The meanings conveyed are ‘location and culture specific’. As pointed out by (Channa 2013 p. 157), these meanings are produced in specific cultural contexts, where there is a shared conceptual and dispositional category of the actors. Also, this shared understanding may be limited to certain members of the community. Thus, the women who are part of such rituals have all the meaning of these, but the rest of the community members may not feel connected, except for being in the audience and performing their role as ‘audience’. It must be emphasized that times are changing and both the women’s social world and the man’s ‘wild’ world is changing. Increasing pressures for them to go stay back in their winter place of Dunda village, impacts of climate change on their sheep rearing activities, with the State policies of building highways affecting their travel routes as their sheep now cannot climb the high walls built on either side of highways. I know look at the Chenchus community from down south, in Andhra Pradesh. Unlike working with Jad Bhotiyas at a personal level, I cannot say the same thing about Chenchus. In the common talk of relatives visiting the Srisailem Temple in Kurnool District, there is a somewhat derisive mention of Chenchus. During my childhood, I had the occasion of visiting a Government School, where the teacher posted was an uncle of mine, who ‘showed’ how the children of Chenchus, never sat down on the benches provided, but always hung about the window sills. The ‘stereotypes’ of looking down at communities persists then and even now. While we admire the wild through national geographic and discovery, the likes of Bear Grylls’s shows, the lives of the forest dwelling communities are little respected. Their knowledge of the ’ways of the forest’ are discounted, and we would like to present our own world as ‘supreme’. Drawing upon insights from ethno medical practices in studies of medical anthropology, I believe I can bring an understanding of health and healing as is being practiced among Chenchus. I would now like to discuss the understanding and insights derived from medical anthropology as a sub discipline of anthropology to account for the ‘experience and distribution of illness, the prevention and treatment of sickness, healing processes, the social relations of therapy management and the cultural importance and utilization of pluralistic medical systems’. In this, it enables a holistic examination of health practices of the indigenous communities. Using the social construction of knowledge approach, it can unravel the politics of science and scientific discovery, hypothesis testing. There is a need to examine ‘how the health of individuals, larger social formations and the environment are affected by interrelationships between humans and other species; cultural norms and social institutions; micro and macro politics; and forces of globalization as each of these affects local worlds’ (Society for Medical Anthropology 2019).

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Conceptualization of health and healing among Chenchu Community The Chenchus reside in the Nallamala forest areas of the middle sector of Eastern Ghats. Officially they are classified as particularly vulnerable tribal group, from a previously used nomenclature of primitive tribal group. The Chenchus are aborginals of India with their main livelihood activity as foraging and hunting. They have been studied extensively by anthropologists, starting with the ethnographic studies by C. von Furer-Haimendorf, in 1940, who portrayed them as hunter-and-gatherers from the Nallamala forest, where they hunted, collected honey, dug wild tubers, and gathered. Subsequently this community has been extensively studied by Bhowmick (1992) and others (Ivanov 2014). The natural dependence on forests has been articulated in several studies on Chenchus (Subba (2010), Hemalata and Reddy (1982), Ivanov (2014)), which is also changing drastically, ever since their habitats are declared tiger reserve and now their areas identified for uranium mining by UCL. Their lives are closely enmeshed with their natural resources. They do not consider themselves separate from nature, much like the Bhotiyas. They are excellent foragers and honey collectors. Dependent on the forests enables them to develop insights into the ‘ways of the forest’. Thus, they would typically be able to identify various bird calls, animal signs and the flowering of the plants and trees. Over centuries of such passing of ‘indigenous knowledge’ through their socialization processes have ensured that their ‘knowledge of the forests, streams and rivers’ is preserved and utilized for their life and sustenance. The forest also serves as their store house of medicines and food source. A 2005 paper published in the Indian Journal of Traditional Medicine continues in this tradition and presents the ethno-medicinal practices related to common ailments experienced by women. Ratnam and Raju (2005) thus have identified about 25 plant crude drugs with 16 plant families involved. Of these 25, two are used for menorrhea, seven for leucorrhoea and menorrhea and 16 species are used only for leucorrhoea. Health and illness are thus to be located in this context. Their health practices emanate from their close bonding with the forests. Many of the common ailments have remedies, with medication prepared from the barks, rots, leaves, flowers and seeds of the various plant species found in their region. They have both an instrumental as well as symbolic value for these plants and animals. The protector of their health and well-being is Mallanna, the reigning deity at Srisailem. They have their local deity too known as ‘Porulamma’. Life activities are bound in a series of appropriate offerings to the deities. They also believe in the rain god ‘vana devata’ (vana meaning rain and devta meaning God) who ensures plentiful rain for their forests to thrive and survive (Subba 2010). They reason out that their health is due to the blessings of their deities and spirits. Ill health can be due to ‘secular’ reasons of drinking bad water, eating bad food, having irregular habits, or due to insect, snake bite and changing seasons for which remedies are available. In fact, Morris (1989) points to the range of symptoms and

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treatments available, ranging from common fevers, heart ailments, to child birth. This also signifies to their extensive knowledge of available species of plants around their natural habitat. These can be practiced by any one and thus belong to ‘folk medicine’, where remedies or known to everyone in the community. However, if the symptoms persist, a medicine man known as ‘naatu vaidyudu’ must be consulted. If the illness cannot be understood, then a divination authority is consulted to find out the cause of the disease. These are known as Gadde Cheppu Vadu, Tappetagallu, sakunamrai who find out reasons and also suggest remedies in the form of amulets, medicines or rituals. The Chenchus believe that not only evil spirits and angry gods but also several natural, physical and psychological conditions, i.e. fright, excessive cold and heat, indigestion of food, excessive bile, dislocation of internal organs and changes in the weather and water etc. are the causes of diseases (Hemalatha and Reddy 1982, p. 39).

The conclusion interestingly points to the aspect of world view of Chenchus and how their folk medicinal systems are culturally suitable way of tackling diseases.’ it still functions within the context of the values, attitudes and beliefs of the people who comprise that society’ (ibid, p. 44). Morris (1989) lucidly presents the folk medicine practices followed by Chenchus for all the common ailments suffered during the course of a life cycle. The practical remedies mentioned above are utilized for curing external injuries and for the treatment of a wide variety of ailments. But if an illness is of a chronic nature or does not respond to these empirical remedies, then its cause may be attributed to the malevolence of a deity or the angered jiv (soul) of a deceased relative. During a serious illness therefore, a divinatory rite may be conducted, to ascertain which deity is responsible for the patient’s condition. Both women and men act as diviners, and as Haimendorf writes, divination is employed for no other purposes than the curing of sickness or speeding the delivery of a child (1943:200) (Morris 1989, p. 30).

The concept of diseased relative is akin to what Bhotiyas experience in relation to their dead. Similarly, the practice of divinatory rites to find out the cause behind illness is another significant similarity. Though ‘dead as ‘living’ with them is a unique notion of Bhotiyas, with respect to the two communities under discussion. Further, Chenchus believe that dead relatives desire to be remembered with food offerings, and if this is missed, then they take on a malevolent ghost form known as ‘deyam’ or in the Telugu spoken in other mainstream communities as ‘deyyam’, which can inflict misfortune on the families. This needs to be cured through ‘Propitiations to deities or deceased relatives’. The Chenchu medicine thus implies both a personalistic and a naturalistic disease etiology. The use of charms, incantations and shamanistic seances (orikaf) i, therefore an important aspect of Chenchu medical practices.......several medicines that are used to ward-off malevolent spirits, and the use of turmeric as a protection against the ‘evil eye’(Morris 1989, p. 31).

Further, Chenchus show an eclecticism in terms of responding to health issues is evident, when they are not averse to receiving, ‘pedda mandu (literally big medicine in Telugu), then and now (Tekumal 2018).

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Towards professional medicine the Chenchus have no marked aversion, although they tend to consult allopathic and Ayurvedic mainly with respect to serious or chronic ailments. Chenchus from the more remote forests not infrequently attend the mobile medical units at Mannanur and Kondanagula, where they receive treatment from Avurvedic doctors (Morris 1989, p. 31).

Recent studies also point towards the continuity of this tradition. However, the forest is no longer the same, as development has made these forests slowly disappear. The area of the Chenchus is declared as Tiger Reserve and now there is a looming threat of uranium mining as the forests are identified as having rich sources of uranium. The concept of health is located in their concept of panam, meaning life. Also this concept includes mental health too. Panam Baga ledu means life is not good, is a common way to refer to their health and well-being in Telugu (Tekumal 2018).

Framing Mental Health in a cultural context Thus, we see that there are continuities in terms of following their way of living, including their ideas of health and well-being, but these are subject to changing life circumstances due to shrinking forests. Many of the foraging, especially honey collection is being drastically reduced as they complain about reduced bee population because of overuse of pesticides in the nearby plain areas. The notion of achieving mental health thus needs to be firmly located in their cultural contexts. There is a performativity associated with the ‘act of healing’ that is at once cultural, hence also gendered. The ‘agency’ of the ‘ritual performers’, in the two communities depends on the ‘assigned social role’ that is meaningful in their own culture. Affliction, appeasement all depend on the reference framework. Polit (2006) argues in her interpretation of the ‘performative roles’ by the women of Chamoli, Uttrakhand, that ‘Gender performativity is one of the vehicles that produces a gendered subject’, where performativity located in gendered habitus’ wherein, she combines the ideas of performativity and habitus ideas of Judith Butler and Pierre Bourdieu, respectively. The Chamoli women exercise an agency that is concomitant with their social roles. In this, there is no individual agency, but collective agency that is shared and distributed, that exists in connection with others, the family members, friends, and supernatural beings and so on and makes immense sense to them. This reflection about their gender, their age, their status, or their role—enables them to perform as, for example, daughters, wives, or mothers and thus not only act strategically but also consciously. But this performance of course happens within a framework of common understanding within a social world. Meaningful actions, and creative actions of agency therefore need to occur within—and are for this reason restricted by—such a framework of common understanding. And this common understanding is based on gendered performative practices (Polit 2006, p. 342).

Sax (2014) discusses the relevance of ritual healing in which it does not treat the symptoms nor heal the disturbed mind, but seeks ‘restoration of social relationships’

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and ‘restores a cosmology; or better, it restores the suffering person to an appropriate place within his or her cosmology (p. 841).

Understanding the dynamic context and moving forward In Conclusion, I would like to focus on the prescriptive guidelines given by WHO (2019) Focus in Women’s Mental Health. WHO’s Focus in Women’s Mental Health • Build evidence on the prevalence and causes of mental health problems in women as well as on the mediating and protective factors. • Promote the formulation and implementation of health policies that address women’s needs and concerns from childhood to old age. • Enhance the competence of primary health care providers to recognize and treat mental health consequences of domestic violence, sexual abuse, and acute and chronic stress in women. (WHO 2019, p. 3). At the same time, the deleterious effect of changing natural conditions on men’s mental health of Jad Bhotiyas and Chenchus also need to be noted and worked towards. While change and transition are imminent, communities are increasingly facing threats from natural and changing climatic crises, that destroy their habitats and their contexts of work and living. These threats are occurring with frequency that leaves little scope for communities to learn once again to adapt to changes. As the social determinants of mental health document by WHO articulates succinctly, Social arrangements and institutions, such as education, social care, and work have a huge impact on the opportunities that empower people to choose their own course in life. Experience of these social arrangements and institutions differs enormously and their structures and impacts are, to a greater or lesser extent, influenced or mitigated by national and transnational policies. (World Health Organization and Calouste Gulbenkian Foundation 2014, p. 9).

Factors detrimental to health may not lie within communities, but perhaps in the natural and social world they inhabit, subject to increasingly aggressive posturing by both state and mainstream society. Further, state policies are becoming centralizing that to some extent has upset their autonomy. There is a need to look at the context in a more nuanced and holistic manner for building better understanding and designing interventions in health and well-being, with an active participation of the communities concerned.

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References Bhowmick, P. K. (1992). Chenchus of the forest and plateaux: A hunting-gathering tribe in transition. Calcutta: Institute of Social Research and Applied Anthropology. Channa, S. M. (2013). The inner and outer selves. cosmology, gender and ecology at the himalayan borders. New Delhi: Oxford University Press. Cox, N., & Webb, L. (2015). Poles apart: Does the export of mental health expertise from the global north to the global south represent a neutral relocation of knowledge and practice? Sociology of Health & Illness, 37(5), 683–697. https://doi.org/10.1111/1467-9566.12230. Ecks, S. (2016). Commentary: Ethnographic critiques of global mental health. Transcultural Psychiatry, 53(6), 804–808. Gopalkrishnan, N. (2018). Cultural diversity and mental health: Considerations for policy and practice. Frontiers in Public Health, 6, 179. https://doi.org/10.3389/fpubh.2018.00179. Hechanova, R., & Waelde, L. (2017). The influence of culture on disaster mental health and psychosocial support interventions in Southeast Asia. Mental Health Religion Culture, 20, 31–44. https://doi.org/10.1080/13674676.2017.1322048. Hemalatha, P., & Reddy, B. V. S. (1982). The folk medical practices among a tribe of Andhra Pradesh. Bulletin of the Indian Institute of History of Medicine, 12, 39–44. Ivanov, A. (2014). Chenchus of koornul district: Tradition and reality. The Eastern Anthropologist, 67, 3–4. Kirmayer, L. J., & Pedersen, D. (2014). Toward a new architecture for global mental health. Transcultural Psychiatry, 51, 759–776. https://doi.org/10.1177/1363461514557202. Retrieved from https://journals.sagepub.com/doi/pdf/10.1177/1363461514557202. Kitayama, S., Markus, H. R., Matsumoto, H., & Norasakkunit, V. (1997). Individual and collective processes in the construction of the self: Self enhancement in the United States and self-criticism in Japan. Journal of Personality and Social Psychology, 72, 1245–1267. Lee, B. O., & Kirmayer, L. J. (2019). Dang-Ki healing: An embodied relational healing practice in Singapore. Transcultural Psychiatry. https://doi.org/10.1177/1363461519858448. Morris, B. (1989). Chenchu folk medicine. Bulletin of the Indian Institute of History of Medicine, XIX, 21–32. Patel, V. (2001). Cultural factors and international epidemiology: Depression and public health. British Medical Bulletin, 57(1), 33–45. Retrieved from https://doi.org/10.1093/bmb/57.1.33. Polit, K. M. (2006). Keep my share of rice in the cupboard: Ethnographic reflections on practices of gender and agency among dalit women in the central himalayas. Dissertation submitted to The Faculty of Behavioural and Cultural Studies > Institute of Ethnology University of Heidelberg. Retrieved from. https://pdfs.semanticscholar.org/e716/c6199b2fd68536a0df2ccb9ece9036 2d2935.pdf. Ratnam, V. K., & Raju, V. R. R. (2005). Folk medicine used for common women ailments Adivasis in the eastern ghats of Andhra Pradesh. Indian Journal of Traditional Knowledge 4(3). Retrieved from http://nopr.niscair.res.in/bitstream/123456789/30680/1/IJTK%204(3)%20267-270.pdf. Sarkar, S., & Punnoose, V. P. (2017). Cultural diversity and mental health. Indian Journal of Social Psychiatry, 33, 285–287. Sax, W. (2014). Ritual healing and mental health in India. Transcultural Psychiatry, 51(6), 829–849. https://doi.org/10.1177/1363461514524472. Society for Medical Anthropology. (2019). What is medical anthropology? Retrieved from http:// www.medanthro.net/about/about-medical-anthropology/. Subba, R. C. (2010). The life of hunting and gathering tribe in the eastern ghats Delhi: Kalpaz Publications. Tekumal, S. (2018). Power knowledge and practice: a study of health care systems of chenchus. Unpublished M.Phil. Dissertation, Department of Social Work, University of Delhi. Townsend, J. M. (1979). Stereotypes of mental illness: A comparison with ethnic stereotypes. Culture, Medicine and Psychiatry, 3(3), 205–229.

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White, G. M., & Marsella, A. J. (1982). Introduction: Cultural conceptions in mental health research and practice. In: A. J. Marsella & G. M. White (eds), Cultural Conceptions of Mental Health and Therapy. Culture, Illness, and Healing (Studies in Comparative Cross-Cultural Research), vol. 4. Springer, Dordrecht. DOI https://doi.org/10.1007/978-94-010-9220-3_1. WHO. (2018). Mental health: Strengthening our response. Web page Accessed from https://www. who.int/news-room/fact-sheets/detail/mental-health-strengthening-our-response. WHO. (2019). WHO|Gender and women’s mental health. Accessed from https://www.who.int/men tal_health/prevention/genderwomen/en/. World Health Organization and Calouste Gulbenkian Foundation. (2014). Social determinants of mental health. Geneva, World Health Organization. Retrieved from https://apps.who.int/iris/ bitstream/handle/10665/112828/9789241506809_eng.pdf;jsessionid=6A0145FAFF9C4BB28A 6D78B4916F03D9?sequence=.

Part II

Mental Health Scenario in India: A Gendered Lens

Chapter 6

Mental Health Aspects of the ‘#MeToo Movement’: Challenges and Opportunities R. Srinivasa Murthy

Introduction It was 75 years back, Smt. Kamaladevi Chattopadhyay delivered the Presidential address to the All India Women’s Conference, at Bombay (current Mumbai), on 7 April 1944. She noted: ‘It is equally erroneous to hold the ‘nature of man’ responsible for women’s disabilities and give the women’s movement an anti-man twist. It is the nature of our society which is at fault and our drive has to be directed against faulty social institutions. The Women’s movement, therefore, does not seek to make women either fight men or imitate them. It rather seeks to instill into them a consciousness of their own faculties and functions and create a respect for those of the other sex. Thus, alone can society be conditioned to accept the two as equals. To fit women theoretically and practically into this scheme, women have to be encouraged to develop their gifts and talents. This has therefore to be one of the main planks of the movement’ (emphasis added) (Guha 2010). Her message is relevant to the current situation in India and the world, at many levels. The continuing messages are on the importance of gender relationships, the slow pace of the changes in the gender relationships and more importantly, the direction in which the gender relations should move. All of these are as relevant as it was 76 years back. It is this sense of progress and stasis of rights of women and its special reference to mental health that forms the focus of this chapter. The current chapter addresses the mental health implications of the historic changes anticipated by the ‘#METOO’ movement, for the males and females and the larger society, which has completed two years. R. Srinivasa Murthy (B) Former Faculty of National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2020 M. Anand (ed.), Gender and Mental Health, https://doi.org/10.1007/978-981-15-5393-6_6

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The chapter will cover three broad areas, namely (i) the experiences of women leaders about the disadvantages of women through human history, (ii) recent understanding of mental health and (iii) the approaches to harmonize the changes in gender relationships and mental health of the population.

Nirbhaya Atrocity in 2012 It is relevant to recall the response of the leaders of society at the time of the December 2012, Nirbhaya atrocity (Appendix 1). The common themes were understanding the social context in which all this is happening, sickness of society, need for change in the popular culture and the need for preventive initiatives. The central message was the need to address the issues, ‘NEED FOR CHANGES IN ALL ASPECTS OF SOCIETY’ and that it cannot be business as usual.

‘#METOO Movement’ The whole world and India in particular are giving attention to the ‘#METOO movement’ to address the issues of patriarchy, gender inequalities, gender violence and related issues. The following headlines in the media reflect the mood of the movement Box 6.1: Box 6.1 Recent headlines of the times during #METOO movement ‘Not a single woman who does not have a #MeToo story’; ‘Naming and shaming these culprits on social media is the only option’; ‘Men are trembling’; ‘The everyday hazards of being in the field’; ‘#MeToo will change the narrative forever’; ‘India is the most dangerous country for women. It must face reality-A global survey exposes a vicious cultural agreement that women have little value in our society’; ‘India’s abuse of women is the biggest human rights violation on Earth’; ‘The India, I grew up in has gone. These rapes show a damaged, divided nation’.

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Gender Disparities Through Human History It is important to recall, beyond the current anguish expressed above, gender-equation has been an issue in every age, in which every culture and society has addressed in their own ways and the life has gone on. It will be difficult to define what is ideal, but everything is apparently not right in modern times. Change is the way forward. Can we harmonize the changes with positive mental health of the population? The following writings from a number of leading women from a range of different sectors of the society show the deep seated nature of the disadvantages experienced by women. Gender emerges as the major factor in marginalization of an individual, more powerful than class or caste. Mahasweta Devi’s fiction not only provides a semiotic (rather than symbolic) space for the articulation of subaltern women’s acts of resistance and defiance but also shows how women are ‘subalternized’ by the ideological construction of gender (Devi 2003). In my lifetime, I have seen this story come out into the open, I have witnessed the slow awakening of one half of the human race, I have seen this struggle slowly achieves a legitimacy and gets identified for what it is—the struggle of an oppressed people. This struggle, the struggle of women to be considered equal human beings, is a part of my story. Or rather, I am a part of it, as an insider, an observer and above all, as a raconteur (Deshpande 2018). ‘It may be seen that almost every poem of Kamala Das expresses one or the other aspect of Das’s life, her feelings, her unfulfilled love; her exploitation, her disillusionment, her feminine sensibility and her rebellion against male-dominated society’(Kohli 2013). A leading lady judge has this to say: “Who knows, if there are many such “I’m sorry” meetings, our society may also slowly cure itself of the malady and become an equality based, respect driven society” (Sridevan 2018). In all the years of India’s Independence, the country has had only one woman Prime Minister and one woman as chairperson of the University Grants Commission. Has a woman ever been the Chief Justice of India? And despite the much-trumpeted equality before God that all religions preach, can any woman hope to head a church, mosque or math? Most fatally for the species, most of them are taught to despise women and view them with either suspicion or derision. It begins very early with statements like, “You can’t join this game… it isn’t for girls,” and goes on to “That is your responsibility, not mine, because…”. …….How often have we seen women struggling with heavy bags while a husband or son walks ahead of her unburdened by any of the grocery? We need to remember that women are homemakers, not home-slaves. (The Hindu 2018). There are also nuanced presentation of the complex issues. One example will illustrate the same. In a short-story titled, ‘Standing Outside’ (Anand 2018) about for heartless uncles and other predators. The emotionally touching story is that of a mother visiting her son, who is in jail for abusing his sister’s daughter of young age. The reflection brings

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out the important aspect of her behaviour discriminating her daughter in favour of her son through childhood and how this led to his feeling ‘entitled’. She was confronting ‘You are the mother of a rapist. You brought up a rapist, you witch’. She recalled how, when he was irritable, she cajoled him, ran circles around him, got his sister to fetch a cold glass of water and his slippers. She shuddered as she recalled a time when she slipped his shoes off for him as he flung himself onto the bed with them on, although she had a strict ‘no shoes’ rule in the house. He was the only one who was allowed to break that rule. He was the only one who was allowed to get away with breaking rules that did not suit him”. At another point in the story, she realizes: But I did. I was wrong for making you believe that you were above women, that you held right of way over them. That yes, that you could rape them and get away with it. I did not, you did not…. ‘Yes, I did, the little things made the difference. I should have shown you that you were equal. Not more, not less. And I should have held you accountable. But I did not’. (emphasis added)

The story brings out the complex roles of different persons and many little things that contributed to the final violent criminal sexual act of violence. Whether it is the recognition of gender disparities and relationship issues or the ‘#METOO’ movement, there is no doubt that need for change is the order of the day. The question is the process of change and how to maximize the positive benefits of change and minimize the negative fallouts of the change. It is well recognized that changes at the individual, family or community level changes are associated with mental health implications. The following section summarizes the recent developments in mental health relevant to social change in general and the #METOO movement.

Recent Understandings of Mental Health The important aspects of emotional health that is relevant to the discussions of #METOO movement and the consequent changes in the society are the following: • Changes and stresses of all types are associated with mental health implications; the expected changes in gender relations will be associated with stresses in both the sexes (Murthy 2018a, b); • Childhood trauma of any type is associated with negative mental health consequences throughout life (Murthy 2014); • Domestic violence is associated with higher levels of mental disorders. For example, a recent study from reported high rates of domestic violence in women living in slums (Begum et al. 2015). Shift in power equations can, paradoxically, temporarily increase rates of domestic violence; • Inequality of all types is associated with increased mental disorders. Wilkinson and Pickett (2010) present international research studies showing associations

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with drug abuse, teenage pregnancies, violence, imprisonment and quality of life. As the movement makes progresses, we can expect less inequalities between sexes, and this raises the possibility of reduction of inequality as a contributor to well-being of the total population; Urbanization, slums: Mobility of populations and urbanization affects mental health through the influence of increased stressors and factors such as an overcrowded and polluted environment, high levels of violence, access to illicit drugs and reduced social support. In most developing countries, over 10% of the population living in urban areas live in slums. For example, low-paid urban workers often live in crowded spaces with poor basic sanitation, food supplies and shelter, as well as few—if any—basic governmental and social support services (Murthy 2018a, b). Loneliness: A number of longitudinal studies indicate that loneliness proceeds depression, sleep difficulties, high blood pressure, physical inactivity, functional decline, cognitive impairment and increased mortality. Physical and mental health components of quality of life were significantly reduced by loneliness. Severe loneliness was associated with reduced patient satisfaction (Musich et al. 2015). Social networks are vital for mental health: In a longitudinal study, researchers from Harvard and Peking universities analysed 12 years’ worth of data from men and women aged 65 years or older and found that loneliness and depressive symptoms appeared to be related risk factors of worsening cognition (Dickens et al. 2011). At the beginning stages of readjustment of relationships, there is likely to be greater confrontation and reduced cohesion; Measures that promote resilience and post-traumatic growth can mitigate the negative effects of adverse situations like exposure to disasters/conflicts, severe life threatening situations like cancer and result in positive growth of individuals (Southwick and Charney 2018). This positive aspect points to the need for making emotional support to the total population, going through massive social changes associated with the #METOO movement.

There is support that the above factors are relevant to the gender relationships from the recent studies. Women as a group are experiencing emotional stress comes from a recent book, CHUP, which interviewed over 600 women. She presents the multiple challenges and complexities experienced by Indian women (Narayan 2018).

Need for Changes Every day newspapers, mass media are projecting the many inequalities between the sexes. This could be the less than 10% of women in policing, the differences in health conditions in women from anaemia to childbirth, the gendered school books, fairy tales, movies, advertising, politics, professions, board rooms, etc. The crying need is for changes at all levels and in all social institutions. There is no doubt that the issue of gender roles and relationships needs to be deliberated upon on a continuous

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basis by the society for the sake of a healthy society. As noted in the beginning of the chapter, the changes needed are clear, but they are likely to occur over time and not overnight. Further, the changes are likely to occur in stages. As I was closing the writing of this chapter, I read the following news item: ‘Hundreds of thousands of women across Switzerland have taken to the streets to demand higher pay, greater equality and more respect, protesting that one of the world’s wealthiest countries continues to treat half its population unfairly’….’We realise there has to be a lot more than this—the culture of sexism is part of everyday life in Switzerland, it’s invisible, and we are so used to just getting along that we hardly even notice it’s there’. (Henley 2019) The need for change is universal. Reporting of a few cases of #METOO is neither the best way to understand the situation or the best way to address the situation. Considering all the women as victims and as a result all men as perpetrators will not lead to healthy changes. We have seen the reaction of society in the case of Nirbhaya episode. Little seems to have changed since, unfortunately in some ways it seems to have worsened. We probably are not asking the right questions nor acting at the right level or on right targets. #MeToo and similar cases have been happening all along, and people in society have known it. Legal remedy is just one of the remedies, which may not be the best one or the most effective one. However, there should be systematic engagement of the society to prevent or protect against such and similar unfortunate situations and work towards harmonized gender relationships.

Interventions As I reach the concluding section of the chapter, the experience of participating in a conference, 40 years back, titled, ‘If change is the answer, what is the question?’. The conference was addressing issues of professional roles and work, with the move from mental hospitals care to community care. There was much confusion and more of apprehension about the changing roles and place of work. Similar is the situation, with the #METOO movement. The road ahead to harmonize the gender relationships and mental health of population requires interventions at many levels. Few of the recent opinions of leaders in this field is illustrative of the same. This is in addition to the similar views expressed after the 2012 Nirbhaya case. Karat (2019), in her article suggests, ‘The way forward is through increased public action for social change and enforcement of a code of accountability and responsibility on the Central and State governments to implement the recommendations necessary to make India safe for its women and children’; Abdulali (2019), noted in the recent issue of India Today: ‘It is not easy to feel outrage over this brute crime, what we must focus on is real change, real justice, and real compassion instead of the empty satisfactions of orgiastic cruelty’

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Roy (2019), in her recent article titled: Needed: Male finishing school, observes: ‘India’s infamous ‘rape culture’ will change when Indian men change’…the only answer is substantive social transformation, and there are no easy shortcuts to this’; Gupta and Sharma (2019) share from their work ‘The Silence and the Storm’, in The Hindu, interview opines: ‘why despite laws being reformed, social structures that justify the violence have remained the same over the decades….. The government made some changes in the law, yet the system that implements the law, the justice delivery system, remained the same.’ A positive suggestion to address specific issues is offered by Santhanam (2019). ‘In an increasingly unequal world, March 8 (2019), gives us the opportunity to ask ourselves how much more is to be done and how it is to be accomplished. Instead of allowing a day rooted in protest to be taken over by consumerism, women could mobilize around specific issues—better sanitation facilities and better wages—and make sustained demands for effective change in their conditions’. Prof. Pramod Singh, Psychiatrist, looks for gender relationships should not move towards forcing a competitive-homogenization and blurring of the boundaries between men and women. Men and women should, instead, learn to live together amicably and complimentarily (Singh 2019). The impact on the male psyche is reflected in a recent article by Walker (2019) refers to the changes in the reported 20% increase in self-help books as follows: ‘It’s almost like male readers are looking for guidance or reassurance on how to be a man in a post #MeToo world,….It’s a noticeable skew which has never really happened before’. Bola (Bola 2020) calls for ‘We need to redefine manhood. Our warped ideas are causing a mental health crisis’. Professional groups have addressed some specific aspects, like gender in doctor– patient relationships. A good example of bringing about change related to ‘maintaining sexual boundaries in medical interaction is that developed by the Indian Psychiatric Society in 2016 (Appendix 2) (Kurpad and Bhide 2017). Another example is presented by Narayanan (2018) book CHUP-Breaking the silence about India’s women where she identifies seven habits that women must learn to change (Box 6.2) Box 6.2 7 Habits that women must learn to change (Narayan 2018) 1. 2. 3. 4. 5. 6. 7.

Denial of the body; Not talking about the self; Pleasing behaviour; Social isolation especially not networking with other women; Confused sexuality; Placing duty above desire and Dependency.

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The voices for change are everywhere. The challenge is to find a way to make it happen. The chapter considers some generic approaches to address the change in gender relationships.

Mental Health Interventions Societies, all around the world, are heading towards major changes in the gender relationships. However, the change requires new solutions, similar to what happened when changes occurred in other spheres of life. For example, the current situation is like that described by late Girish Karnad, about changes in theatre technology: ‘The new technology could not be divorced from new psychology. The two together defined a stage that was nothing like that we had known or suspected’ (Karnad 2018). Similar is our situation of changing gender relationships needing a ‘new ways for gender relationships’.

Role of the Mental Health Professionals The current chapter and the other chapters of the book provide enough evidence of the male-oriented organization of the society and the disadvantages of women in the current societal organization, throughout human history, and these have emotional impacts. There is need to change this to bring equal opportunities to women, so clearly outlined by Smt. Kamala devi Chattopadhyaya, ‘It is the nature of our society which is at fault and our drive has to be directed against faulty social institutions’. The challenge is not to debate the goal but find the road to reach there, with mental health as one of the partners of such changes. There have been major, if not massive changes in gender relationships, that I have seen in my lifetime. The way my mother perceived and lived her life and the life of my wife and more than that, that of my two nieces is worlds apart. There is gradual progress towards greater empowerment of women. However, there is much that needs to change. The changes will occur overt time, and there has to be focus on the harmonious changes and not only the rapidity/immediacy of the changes. Though there is no set ‘speed limit’, it could prove counterproductive to expect the changes to occur immediately. The change in the gender relationships and ‘optimization of women as equals’ in social life would require changes at the level of individuals, families and communities. There will be both losses and gains, by all concerned, and these will involve everyone in the society. One single most important finding of the last one century of mental health research is the recognition change can be stressful, and there will be both losers and winners associated with changes (Murthy 2018). Luckily, we have now significant amount

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of knowledge to minimize the negative effects along with maximize the positive benefits (Southwick and Charney 2018).

Mental Health Interventions It is important to recognize that there are three components to the scope of mental health. This was beautifully outlined by Prof. M. V. Govindaswamy, the first director of All India Institute of Mental Health, Bangalore, as follows: The field of Mental Health includes three sets of objectives: One of these has to do with mentally sick persons. For them the objective is the restoration of health. second has to do with those people who are mentally healthy but who may become ill, if they are not protected from conditions that are conducive to mental illness which however are not the same for every individual. The objective for these persons is prevention. The third objective has to do with upgrading of mental health of normal persons, quite apart from any question of disease or infirmity. This is POSITIVE MENTAL HEALTH (emphasis added). It consists in the protection and development at all levels of human society of secure, affectionate and satisfying human relationships and in the reduction of hostile tensions in persons and groups’ (Rao 1970).

The mental health implications of the #METOO movement and changing gender relations are considered under the above headings of promotion of mental health, prevention of mental disorders and care of persons with mental disorders. It is best to start with the recognition of the need for a lot of new information about the impact of the changing gender relationships. There is an urgent need to understand the impact of changes in both men, women and the larger society. Change will be challenging at many levels, especially at the emotional level. It will ‘hurt’ everyone. Let me share one such experience. As part of the CHUP study of 600 women, the following was the experience of interviewers. ‘One observation emerging from the study was the new learning for the investigators and the emotional strain of carrying out the enquiry. …..There was much I did not know when I started this inquiry. I had not foreseen the deep emotional impact the interviews would have on my team and me. It was cumulative. It crept on us. Young women doing the interviews started telling me that listening to women’s stories was stirring up trouble in their own psyches. Not had I foreseen the torrent of emotions talking would release in women being interviewed. I had been afraid women would have no patience for the interviews, but instead they started thanking us for letting them talk about issues they had kept bottled. It was like witnessing the breaking of dams. In the absence of any judgement, the interview process became a safe emotional space. My researchers wrote their own stories. Some continued over several months. I offered support based on my experience in leading groups in emotional literacy. Mostly I just listened. It started affecting me as well stirring up my memories’ (Narayan 2018).

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There is an urgent need for monitoring the effects of changing gender relationships and to ensure that the results of such monitoring are fed effectively into the decisionmaking processes at the national and international levels. This need is greater in the low and middle income countries.

Promoting Mental Health It is important to develop interventions to address the impact at all levels of society, both on the short-term and long-term perspectives. It is best to avoid in these efforts to look the different components of society as competing or contrasting points but as complimentary. Such a harmony of the needs of the individual with that of the processes of changes in gender relationships would be an important contribution of the field as well as adaptation of ideas and practices to the local cultures and communities. The mental health group of Future of Psychiatry (Bhugra et al. 2017), recognizing that psychiatry in the first quarter of the twenty-first century is at the cusp of major changes, identifies the scope as follows: Increased emphasis on social interventions and engagement with societal expectations might be an important area for psychiatry’s development. This could encompass advocacy for the rights of individuals living with mental illnesses, political involvement concerning the social risk factors for mental illness, and, on a smaller scale, work with families and local social networks and communities. Psychiatrists should therefore possess communication skills and knowledge of the social sciences as well as the basic biological sciences.

At the societal level, there is need for rethinking of development. One of the urgent needs is to rethink development from the gender perspective. For too long, society has been driven by productivity as a goal by itself, irrespective of the impact on the individuals in general and women in particular. Specifically, the mental health aspects of urbanization, migration, refugees on women need urgent attention (Murthy 2018). Another important need is for rethinking of mental health. The turn of the twentieth century brought individualism to the forefront of mental health, an important break from the dominant role played by religion till that time. The gains of the focus on individuals have been many. However, there is need to reset the clock to have a harmony between the individualism and community life. Empowering of the individuals and families is the need of the times. This is challenging as noted by Imhasly-Gandhy (2017) a psychotherapist from India: ‘As clinicians and researchers, we are most close to individuals and families and the challenge the transformation of ideals, which have persisted for generations, cannot be changed in the span of a generation by rational arguments. Nevertheless, as psychologists, we can help change the individuals who have suffered and have transformed themselves and in turn influence others, leading to the formation of a critical mass. This broadening of consciousness through discussions and debates has

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an influence on the unconscious of others at large….. we need to have the courage to deal with these issues and not transmit our entire unattended baggage to our future generations’. Although the causes of mental disorders are complex and multiple, solutions have to be local and rooted in local culture, practices and institutions. Traditionally, crisis situations were solved by elders in the family, community leaders and religious leaders. There is a need to rebuild community life through common cultural, social and recreational activities to provide opportunities for group commitment to values and norms of behaviour. In addition, small homogenous communities can build places for people to meet, play and resolve their growth-related problems. Religious centres like temples, gurdwaras, churches and mosques can play a vital part by responding to the needs of the younger generation Towards promotion of mental health, the rebuilding of the individual/family/community can be undertaken by the following measures: 1. The most important task for all interested people in general and mental health professionals in particular is the compilation of the experiences of individuals— men and women, from different age groups, communities, classes and religions, as the experiences are both generic and specific to the live-in situation of individuals. 2. Building a system of ‘emotional literacy’ and emotional self-care is the next important activity as the need for these skills will be in all of the population, as changes affect everyone. The goal should be towards emotional empowerment of individuals (WHO, 2001 and Murthy 2016). 3. Towards creating a generation of gender-sensitive population, life skills education programmes in all schools to increase the emotional development of young Indians, from early childhood, specifically to handle their own body, the interpersonal relationships, responding to violence, and emotions, gender sensitivity; 4. Rebuilding the family cohesion and communication across the different members of the family, through marriage counselling, support to families in crisis; 5. Crisis support mechanisms in the community—helplines, psychosocial care facilities accessible to all people in distress; 6. Accessible and acceptable mental health and substance abuse services to those with mental health problems, like integrating mental health with general health care (WHO 2001), through self-care skills to all of the population (Murthy 2016) and use of information technology; 7. Research into issues relating to changing roles, domestic violence, movies and mental health; study of perpetrators of the violence; evaluation of psychosocial interventions.

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Prevention of Mental Disorders Towards prevention of mental disorders, the focus will be the ‘vulnerable individuals’ and individuals living in ‘vulnerable situations’. There is vast amount of information about this from other societal situations like the work with refugees, migrant populations and more specifically those living in conflict and disaster situations (Christodoulou et al. 2016; Krausz and Choi 2017). In all of these situations, the interventions are to recognize the ‘vulnerability and distress’ as ‘normal behaviour in an abnormal situation’ rather than attributing it to the individual using a diagnostic label (the deviancy model). The groups who should receive emotional support, skills to cope with stress are those who have been traumatized (child trauma victims, sexually abused, etc.), those living in disadvantaged position in the society (migrant women, etc.), single women, elderly women/men. The services for this group should be less of clinical care and more of emotional health skills and lifestyle guidance for mental health. Importantly, we have now sufficient information about ‘Lifestyle Psychiatry’ and ‘Positive psychiatry’ (Jeste and Palmer 2015; Hamber and Gallagher 2015; White et al. 2017). Another measure for prevention is to work towards networking and cohesion of individuals at the level of the homogenous communities in the rural areas, the self-help groups and support groups for those with similar life situations. The larger need is to bring about changes in the family life especially in the area of gender neutral ways of bringing up children. This need is the greatest in the urban areas and in the two working parent units. The use of spirituality to understand the changing gender relationships should be fully explored and integrated into the lives of individuals, families and communities.

Mental Health Care The third dimension is the care for those diagnosed with specific mental disorders. Here, there are many innovative models of care like integrating mental health with primary health care, increasing use of non-pharmacological interventions like cognitive behaviour therapy, group support so that the services are accessible, acceptable and affordable to those who experience mental disorders as part of the changing gender relationships (Murthy 2018a, b). Another way of thinking of mental health interventions would be at the societal level to specific situation levels (Box 6.3).

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Box 6.3 Seven Levels to address male–female relationships that promote mental health 1. Towards mutuality of the sexes—changes at family and community level towards equality of opportunities 2. Changing thinking of men—gender sensitisation 3. Developing role models of women—documentation and dissemination 4. Empowering women with skills of emotional self-care—life skills in schools, etc. 5. Empowering women with skills—assertiveness, purpose of life, etc. 6. Professional norms for setting limits to gender exploitation 7. Crisis support and mental healthcare programmes

Conclusions Changes will occur slowly, in increments and by a wide variety of efforts. The following editorial, one hundred years back in The Hindu (1919) newspaper, speaks for itself The day has surely dawned, when the women of India are going to play an important and interesting role in the country of their birth. Like the caterpillar that gathers and stores up its precious material to encase itself in the shape of the chrysalis which after a few hours rest, bursts its fetter to become one of the most beautiful insects God has created, the Indian woman has passed through all those early stages of training, moulding and transformation to utilize all her talents for the good of her creator, crown and country. Hitherto the Indian woman has contented herself with the atmosphere of her family duties but she has at last realized that her service covers a wider range…India needs her women for countless actions that can raise her from one of lethargy to that of glorious action, man cannot perform the several tasks that his country requires for its general welfare alone, he needs the gentle, subtle, patient and skilful hand of the women around him, and the dawn of that day for India has become perceptible to the Indian woman.

The core issue that #METOO movement confronts is patriarchy in all its manifestations, as pointed by Ramanathan (2019). Patriarchy hits at self-worth and self-esteem. For both men and women, because patriarchy is a way of thinking, not something practised just by men. But patriarchy tells men they are superior - which causes them a certain kind of problem, of inadequacy especially - and women that they are worthless. And they can only find some worth at least by being there to serve men. And the problem begins ….it is therefore no wonder that men wonder why women complain when they are paying attention to them, or when they are asking for what is their due. Oh, well. The women’s movement has been working to dislodge this problem with worth and worthiness and worthlessness.

The larger challenges and opportunities for change of the current complex situation in the world are best presented by the Global Risk Report (2017) with regard to globalization, and this assessment is relevant to the needed changes in the gender relationships, as follows:

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In summary, the #METOO movement urges us, from the mental health point of view to think of promotion of mental health through changing individual values/norms of behaviour, building resilience in both sexes and reorganization of family life, (social reform) in addition to punishments societal level interventions (police and judicial reforms). Here lies the challenges and opportunities towards an equal society for both the sexes, envisaged throughout human history and articulated by Chattopadhya (2010) 75 years back. Personal Note Writing this Chapter has been very challenging at many levels. However, the most interesting has been the reaction of the many colleagues with whom I interacted to complete this chapter. Their reactions are worth recording as it reflects the confusing situation of our attitude to #METOO movement. There were some who questioned about my being a male, being unsuitable to write on the subject. (Meanwhile, a general comment for men trying to write on matters affecting women is just to start and end by acknowledging that yours is a male perspective; state that it is sincere and well-meaning but probably includes errors and misunderstandings simply because you are not writing about your lived experience). One dear friend asked me ‘why are you getting into this?’ There were others, who were active in this field of work, responded positively to share their suggestions to the draft chapter, about six, but did not do so, in spite of many reminders. The last group, in double digit, was those who refused to do anything to do with the effort. Let me also add that, at a personal level, it has been the most challenging writing of my professional life. All of this indicates that the area of the subject is ‘muddy’ and there is much that is unclear’ and calls for careful navigation. Acknowledgements My sincere thanks to many of my professional colleagues who continuously shared their thoughts and experiences and their suggestions to the drafts of the chapter. Specifically, I want to acknowledge Prof. P. K. Singh, Patna, Prof. Mary Ganguli, Pittsburgh, Dr. Usha Ramanathan, New Delhi, Ms. Suman Gupta, Chandigarh, Dr. Parvati Radhakrishnan, Cochin, Dr. Mamta Sood, New Delhi, and Ms. Jayanthi Narayan.

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Appendices Appendix 1: Voices of the Community to Sexual Violence President of India, Mr. Pranab Mukharjee, ‘let us resolve this death will not go in vain’. Prime Minister Mr. Manmohan Singh, ‘we should channelize emotions to concrete action’ further he assured that ‘we will make all possible efforts to ensure security and safety of women in this country. The Home Minister has already spoken about the steps being taken. We will examine without delay not only the responses to this terrible crime but also all aspects concerning the safety of women and children and punishment to those who commit these monstrous crimes’. Ms. Sheila Dikshit, then CM of Delhi, ‘what is in our society that has resulted in this tragedy. We all have to think about this and find solutions. It is a time for deep reflection’. Home Minister Mr. S. K. Shinde, ‘Government to make changes in the law to prevent such incidents’. Mr. K. P. S. Singh, Minister of State for Home, ‘Government will take steps so that no other citizen will have to go through the same suffering… we should prevent such incidents do not occur and called for change at the level of people-the fault is not with laws but with people’. Ms. KrishnaTorath, Minister noted, ‘we have to do many things. We have to bring about changes in our educational system’ Mr. Soli Sorabjee, ‘concentration on the removing of causes’. Mr. Arun Jaitley, ‘it is time for Indian Society to introspect..we need to create an environment in India so that no woman is treated in this manner’. Ms. Brinda Karat, ‘support to the survivors’. Mr. RamJethmalini, ‘the fault is not with the laws but with the people’. Ms. Brinda Grover, social activist, ‘many things need to be done’. Ms. Ranjana Kumari, ‘our systems have failed’. Ms. Sunita Krishnan, ‘a whole mental health system to support the survivors’. Ms.UrvashiButalia, ‘let us ask how we contribute to rape’ Ms. KiranBedi, ‘prevention comes first’. Mr. Parveen Swami ‘the problem is us’ Some of citizen comments on the mass media were to: ‘rebuild the tone of the society’; ‘need for total societal change’; ‘attitudes are ingrained in our society’; ‘no band-aid solutions’; ‘we must look at it from a societal point’; ‘mindset problem need to be addressed’.

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Appendix 2: Salient Points of the Indian Psychiatric Society ‘Sexual Boundaries in the Doctor Patient Relationship: Guidelines for Doctors’ (Box 2) (25) (1)

It is the ethical duty of all doctors to ensure effective care for their patients. This would mean that their own conduct should in no way harm their patient. (2) Doctors should ensure that they do not exploit the doctor–patient relationship for personal, social, business or sexual gain. (3) In view of the power gradient in the doctor–patient relationship and possible transference issues, doctors are reminded that even “consensual” sexual activity between patients and doctors irretrievably changes the therapeutic nature of the doctor–patient dynamic. (4) Any non-consensual sexual activity would amount to sexual abuse/molestation/rape and doctors would be answerable to the law of the land. (5) It is obviously important for doctors to take a relevant sexual history and perform appropriate physical examination. This should be done sensitively and documented properly in the notes. (6) If treatment that requires the patient to be sedated is used (like electroconvulsive therapy, or any procedure that requires anaesthesia), a nurse should be present during the induction and recovery of anaesthesia. (7) Doctors are reminded that even a relationship with a former patient is discouraged and could be construed as unethical, as the previous professional relationship can influence the current relationship. (8) Though these guidelines pertain primarily to patients, doctors are reminded that similar care should be extended to interactions with students, colleagues and other professionals in the multidisciplinary team- indeed anyone who is in a „power imbalanced relationship” with the doctor. (9) Any failure to follow these guidelines, if reported to the Indian Psychiatric Society (IPS) will be referred to the Ethics Committee. It is suggested that all allegations of SBV be taken up for initial enquiry by the Ethics Committee of the IPS. If considered appropriate, they will refer the case to the local ‘Internal Complaints Committee’ (as required by the Supreme Court mandated law on Prevention of Sexual Harassment of Women in the Workplace (Prevention, Prohibition and Redressal Act 2013.) Though this law pertains to women at the workplace, many hospitals/nursing homes have gender neutral policies which extend to patients too. (10) If any criminal act is reported, then the appropriate process of enquiry by the police should be initiated. Doctors are reminded of their own

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ethical obligation to report unethical conduct by colleagues. (As listed in Sect. 1.7 of The Indian Medical Council (Professional conduct, Etiquette and Ethics) Regulations, 2002). Where children are involved, reporting is mandatory or risks imprisonment (Protection of Children from Sexual Offences Act, POCSO 2012).

References Abdulali, S. (2019, December 16). Wormwood and gall. India Today. Anand, P. (2018, December 22). Standing outside. The Week. Begum, S., Donta, B., Nair, S., & Prakasamm, C. P. (2015). Socio-Demographic factors associated with domestic violence in Urban Slums, Mumbai, Maharashtra. Indian Journal of Medical Research, 141(6), 783–788. Bhugra, D., Tasman, A., Pathare, S., et al. (2017). The WPA-Lancet psychiatry commission on the future of psychiatry. The Lancet Psychiatry, 4, 775–818. Bola, J. J. (2020, January 02). We need to redefine manhood: Our warped ideas are causing a mental health crisis. The Guardian. Christodoulou, G. N., Mezzich, J. E., Christodoulou, N. G., et al. (Eds.). (2016). Disasters-mental health context and responses. New Castle upon Tyne, England: Cambridge Scholars. Deshpande, S. (2018). Listen to Me. Chennai, India: Westland. Devi, M. (2003). Chotti munda and his arrow. Blackwell Publishing. Dickens, A. P., Richards, S. H., Greaves, C. J., & Campbell, J. L. (2011). Interventions targeting social isolation in older people: A systematic review. BMC Public Health, 11, 647. Guha, R. (2010). Makers of modern India. In K. D. Chattopadhyay (Ed.), The socialist feminist (pp. 263–280). New Delhi, India: Penguin. Gupta, S., & Sharma, K. (2019, December 14). The silence and the storm—narratives of violence against women in India—review. The Hindu. Hamber, B., & Gallagher, E. (2015). Psychosocial perspectives on peace building. London: Springer. Henley, J. (2019, June 15). Swiss women strike to demand equal pay: Hundreds of thousands protest against cultural sexism in everyday life. The Guardian. Imhasly-Gandhy, R. (2017). Eros, love and the process of individuation in indian society. In R. Nath (Ed), Healing Room. Harper Element. Jeste, D. V., & Palmer, B. W. (2015). Positive psychiatry—a clinical handbook. Washington: APA Press. Karat, B. (2019, December 05). Rape, impunity and the state of mind. The Hindu. Karnad, G. (2018). Collected plays. Oxford: New Delhi, India. Kohli, S. (Ed.). (2013). Wages of love: uncollected writings of Kamala Das. Noida, India: Harper. Krausz, R. M., & Choi, F. (2017). Psychiatry’s response to mass traumatization and the global refugee crisis. The Lancet Psychiatry, 4, 18–19. Kurpad, S. S., & Bhide, A. (2017). Sexual boundaries in the doctor-patient relationship: guidelines for doctors. Indian Journal of Psychiatry, 59(1), 14. Murthy, R. S. (2014). Impact of child neglect and abuse on adult mental health. Institutionalised Children Explorations and Beyond, 1(2), 150–162. Murthy, R. S. (2016). Self-care for mental health—the new frontier. Different Strokes-Indian Journal of Psychiatry. Murthy, R. S. (2018a). Future of mental health. Asian Journal of Psychiatry, 38, A7–11.

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Murthy, R. S. (2018b). Globalization, market economy, and mental health. In R. K. Chadha, V. Kumar, & S. Sarkar (Eds.), Social psychiatry: principles and clinical perspectives (pp. 508–520). New Delhi, India: Jaypee Brothers Medical Publishers. Musich, S., Wang, S. S., Hawkins, K., & Yeh, C. S. (2015). The impact of loneliness on quality of life and patient satisfaction among older, sicker adults. Gerontology and Geriatric Medicine, 1–9. Narayan, D. (2018). CHUP-breaking the silence about India’s women. New Delhi, India: Juggernaut Books. Ramanathan, U. (2019). Personal Communication, December 2019. Rao, S. K. R. (Ed.). (1970). Dr. Govindaswami lectures and writings. Bangalore, India: Brindavan Printers and Publisher Ltd. Roy, V. (2019, December 14). Needed: Male finishing school. The Hindu. Santhanam, R. (2019, March 15). From revolution to roses on women’s day. The Hindu. Singh, P. K. (2019). Personal communication, Dec 01 2019. Southwick, S. M., & Charney, D. S. (2018). Resilience: The science of mastering life’s greatest challenges (2nd ed.). Cambridge: University Press of Cambridge. Sridevan, P. (2018, December 01). The gendered unfairness. The Hindu. The Hindu, January 26, (2018). The role of the Indian woman. (1919, November 13). The Hindu. Walker, R. (2019, March 9). Stressed Brits Buy Record Number of Self-Help Books. The Guardian. White, R. G., Jai, S., Orr, D. M. R., & Read, U. (Eds.). (2017). The Palgrave Handbook of Sociocultural Perspectives on Global Mental Health. London: Palmgrave-Macmillan. Wilkinson, R., & Pickett, K. (2010). The spirit level: Why greater equality makes societies stronger. NY: Bloomsbury. World Economic Forum. (2017). Global Risk Report (12th ed.). Geneva. World Health Organisation. (2001). World Health Report 2001: Mental health—new understanding. Geneva: New Hope.

Chapter 7

The Intersectionality of Gender, Disability and Mental Health Abhishek Thakur

Introduction Disabled women and girls are of all ages, all racial, ethnic, religious and socio-economic backgrounds and sexual orientations; they live in rural, urban and suburban communities. Disabled women and girls live at the corner of disability and womanhood—with two ‘minority’ identities, a double dose of discrimination and stereotyping and multiple barriers to achieving their life goals. While many women with disabilities derive enormous strength, resilience and creativity from their multiple identities, they also face the consequences of discrimination (Barbara Faye Waxman Fiduccia and Leslie R. Wolfe 1999).

Gender is often understood as the cultural interpretation of sexed bodies, embedded in the society’s roles and norms. Gender, as a relationship between sexes in societies, is usually seen as operating hierarchically—men being more powerful and dominant, while women are less powerful and weaker. Gender is the structure of social relations that centres on the reproductive arena and the sets of practices (governed by this structure) that bring reproductive distinctions between bodies into social processes (Connell 2002). Therefore, to bring together women’s experience of disability with feminist theory from a mental health standpoint requires a thorough re-examination and assessment. An understanding of intersectionality between gender and disability is vital to understand the gendered experiences of women with disabilities. Discussions of the impact of disability on women almost always reveal troubled relationships. There are expectations, often deeply internalized, closely related to stereotypes of femininity and are quite handicapping for the woman with disability (Davis 1984). Women with disabilities are often denied equal enjoyment of their human rights, in particular by virtue of the lesser status ascribed to them by tradition and custom, or as a result of overt or covert discrimination. Needless to say that the plight of women A. Thakur (B) Department of Social Work, University of Delhi, New Delhi, India e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2020 M. Anand (ed.), Gender and Mental Health, https://doi.org/10.1007/978-981-15-5393-6_7

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with disabilities is even worse since they face the double burden of being female and being disabled (Lloyd 1992; Lonsdale 1990). According to Garland-Thomson (2001), women and girls with disabilities face double discrimination and thus ‘live at the corner of disability and womanhood: with two ‘minority’ identities, a double dose of discrimination and stereotyping’. Due to the intersection of two grounds of discrimination, women with disabilities have to put in even greater effort in order to overcome physical and social obstacles, maintain their dignity and realize their full potential (Sumskiene et al. 2016). One of the most prominent feminist disability scholars, Garland-Thomson (2001, pp. 4–5), claims that feminist disability studies bring the two movements together. This is to argue that cultural expectations, perceived attitudes, social institutions and their attendant material conditions create a situation, in which persons that are categorized as both ‘female’ and ‘disabled’ experience double marginalization. Feminist disability theory addresses broad feminist concerns, such as the unity of the category ‘woman’, politics of appearance, medicalization of the body, privilege of normalcy, multiculturalism, sexuality, social construction of identity and the commitment to social integration (Garland-Thomson 2011, p. 16). As Davis (1984) argues: A basic tenet of most feminist philosophy has been that “transcendence” comes not from denying but from coming to live from within one’s self. For all of us the difficult work of finding this self includes the body, but people who live with disability in a society that glorifies fitness and physical conformity are forced to understand more fully what bodily integrity means.

She further puts forth A disabled woman may merely subside into pleasant, feminine passivity, accepting her inability, say, to jog as representing a more generalized inability to be responsible for her life, but she may just as disastrously refuse to develop any realistic understanding of her own body.

Women with disabilities face particular disadvantages in wide areas of day to day life including education, work and employment, family and reproductive rights, health, violence and abuse. Moreover, both gender and disability have both traditionally been seen as products of biology. Gender as a result of biology has been thought to determine all manner of social behaviours on the part of men and women (Meekosha 2005).

Impairment, Disability and Handicap The World Health Organization (2002) defines disability as ‘a lack or a restriction (resulting from an impairment) of ability to perform an activity in the manner or within the range considered normal for a human being’. It refers to damage or loss of physiological, psychological or anatomical structure or function, for example, loss of hearing or vision, deformity of limbs, etc. The concept of disability sprung as an opposition to terminology such as ‘functional disorder’ or ‘impairment’. Such concepts

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emphasize physical, mental or sensory limitations, whereas the term ‘disability’ encompasses the availability of opportunities to participate equally in society and loss or constriction of such possibilities, due to existing physical or social barriers. This change in paradigm has shifted focus from the body as a defining attribute, to social relations that determine personal subordination, in both feminist and disability movements (Shakespeare and Watson 2001; as cited in Sumskiene et al. 2016). In other words, disability is the loss or limitation of opportunities to take part in the normal life of the community on an equal level with others due to physical and social barriers’ (DPI 1982). Humphrey (2016) further elaborates the concept of disability making a clear distinction from any particular medical condition. It is a social construct that varies across culture through time, in the same way as, for example, gender, class or caste. Thus, while impairment is often located in biology (and not in the social context), the disabling conditions are always part of the social environment. Disability is a broad term within which cluster ideological categories as varied as sick, deformed, ugly, old, maimed, afflicted, abnormal or debilitated— all of which disadvantage people by devaluing bodies that do not conform to certain cultural standards. Thus, disability functions to preserve and validate such privileged designations as beautiful, healthy, normal, fit, competent, intelligent—all of which provide cultural capital to those who can claim such status and reside within these social identities. Because disability is defined not as a set of observables, broadly predictable traits, such as femaleness or skin colour, but rather as any departure from the physical, mental and psychological norms and expectations of a particular culture, disability highlights individual differences. In other words, the concept of disability unites a heterogeneous group of people whose only commonality is being considered abnormal. As the norm becomes neutral in an environment created to accommodate it, disability becomes intense, extravagant and problematic (Thomson 2001). Another term often interchangeably used is ‘Handicap’ which refers in the context of a physical attribute, only when it is seen as a significant barrier or when it has an adverse effect on social relationships of the person. From the global perspective, the status of disability is linked to a relatively smaller number of individuals. There is no unified monitoring system that would make it possible to evaluate the total proportion of people with disabilities in society (WHO 2014). As per the estimates of WHO (2011), there are nearly 1 billion (15%) people with disabilities in the world. Furthermore, a large proportion of the world’s population with disability comprises adolescents and young people (Addlakha 2007). In the Indian scenario, the 2001 Census estimated the population of the disabled as 21.9 million (Registrar General of India, 2001), As per latest Census (2011), 2.21% of total population of India is estimated to have disability. Within this percentage, it is important to note that 14.9 million (approx.) comprises men and 11.8 million (approx.) consists of women with disability (Registrar General of India, 2011). Nevertheless, researchers state that ‘persons who have disabilities are the largest minority group in the anyway overcrowded act of multiculturalism’ (Davis 1995 cited in Goodley 2011, p. 2). This social group may be called the invisible, even though it is the largest, minority.

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Gendering Disability The way in which disability is experienced is profoundly affected and determined by gender. With 15% people with disabilities in the world, it is considered as the largest, poorest and the most marginalized minority (WHO 2011). Girls and women with disabilities comprise 19.2% of the world’s population in which the majority (80%) reside in developing countries (Kim 2013). The strands of feminist thought most applicable to disability indeed go beyond a narrow focus on gender alone to undertake a broad socio-political critique of systemic, inequitable power relations based on social categories grounded in the body. Feminism becomes a theoretical perspective and methodology for examining gender as an ideological and material category that interacts with but does not subordinate other social identities or the particularities of embodiment, history, and location that informs personhood. Briefly put, feminism is often conflicting and always complex aims of politicizing the materiality of bodies and rewriting the category of woman combine exactly the methods that should be used to examine disability. It engages with the subject as a cultural issue rather than being an individual or medical one and insists on examining power relations rather than assigning deviance when analysing cultural representations of oppressed groups (as cited in Thomson 2001, p. 4). Disabled people have often been represented as without gender, as asexual creatures, as freaks of nature, monstrous, the ‘Other’ to the social norm. In this way, it may be assumed that for disabled people, gender has little bearing. Yet the image of disability may be intensified by gender—for women a sense of intensified passivity and helplessness, for men a corrupted masculinity generated by enforced dependence (Meekosha 2005). From the perspective of the normative subject, having a disability and being a woman have similar meaning, i.e. both aspects of an identity symbolize subordination, deviation from the ‘norm’ and being ‘different’. Nevertheless, the two aspects of disability and gender gain a very different meaning and weight in the selfconsciousness of women with disabilities. Disability is viewed from the perspective of the social model, and hence, recognizing that disability is either created or made more profound by external environment, social, economic and cultural barriers, whereas gender bias is being neutralized, and thus, systemic barriers that arise due to gender issues are often imperceptible. As a result, disability discrimination promoting structures are being challenged, whereas gender-based order remains essentially unquestioned (Sumskiene et al. 2016). Discrimination on the basis of gender and disability is a fact officially recognized by the 2006 UN Convention on the Rights of Persons with Disabilities (Article 6 CRPD) to which the European Union acceded in 2010. The Convention calls for state measures which will safeguard women’s full enjoyment of all their rights and freedoms, such as equal rights in accessing services, education, employment, health care and a personal life free of torture, exploitation and violence (Davaki et al. 2013). Combining gender and disability, Shakespeare (1994) determined the analogy between the origins of the terms gender and disability. The notion of gender was

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brought up as a counterweight to a female or male body, deeming masculinity and femininity to be socially constructed attributes. Disabled women experience discrimination on the grounds of gender, disability, class, sexuality or age. They are far from being visible in terms of participation and unable to enjoy their rights. Consequently, they constitute a very vulnerable group, increasingly at risk in the current economic climate (Davaki et al. 2013). Both the female and the disabled body are cast as deviant and inferior; both are excluded from full participation in public as well as economic life; both are defined in opposition to a norm that is assumed to possess natural physical superiority (Garland-Thomson 1997, p. 19). Mehrotra (2006) illustrates the peculiarities of the gender system due to which a woman with disability experiences double discrimination: as a female she is opposed to a man, and having a disability, she becomes seen as deviation from the ‘norm’, whereas a ‘healthy’ woman is the ‘ideal’. However, subordination from the perspective of gender is often not noticed due to the full attention being focused on removal of social exclusion on the basis of disability, even though a woman who has a disability is a woman first, who enjoys laughing, putting make-up on and may desire male attention. All of the above restricts opportunities for emancipation of women with disabilities even though awareness of the social aspects of disability promotes positive relation to one’s own identity and aspirations to strive for fully-fledged recognition. However, the gender aspect becomes an assumption of a double ‘detention’. This is because the essentialist rather than social understanding of gender hinders development of a critical approach to the patriarchal order of gender, which would neutralize female subordination to males. Additionally, it defines the concept of femininity as especially narrow, and in sexualized and de-humanizing ways, which do not allow women to positively cherish their relationship with their own femininity. Gender differentials among disabled men and women have been studied by various scholars. Clark and Mesch (2016) explore the intersections of gender inequality and social and communication barriers of deafness among female deaf athletes. Discussing how women with disabilities are at a higher risk for gender-based violence, physical and sexual abuse and exploitation they cite the higher rates of illiteracy, poverty, unemployment and poor health among women without disabilities and men with disabilities (Clark and Mesch 2016; Humphrey 2016). Addlakha (2017) illustrates how gender identity and disabled identity interact in different ways for men and women: ‘Disabled females suffer a double disadvantage in that while they cannot enter traditionally male occupied roles, they are also denied access to normative female roles like wifehood and motherhood’. She quotes Fine and Asch: ‘Whereas disabled men are obliged to fight the social stigma of disability, they can aspire to fill socially powerful male roles. Disabled women do not have this option. Disabled women are perceived as inadequate for economically productive roles (traditionally considered appropriate for males) and for the nurturant reproductive roles considered appropriate for females’ (1985, p. 6).

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Ignorance of Sexuality There is an overarching obsession with female beauty across the world reiterated by various institutional structures including family, school and media among others (Anand 2014). In fact, femininity is represented not as a social, structural or psychological quality but mostly as an attribute of a body. Gill (2007) highlights the overemphasized obsession with a human (female) body by media. Disabled persons are rarely considered to be or seen as attractive physically rather ‘asexuality is intrinsically associated with persons with disabilities, particularly women with disabilities’ (Morris 1992). Furthermore, correlations are also made between femininity and possession of a ‘sexy body’, rather than such characteristics as affection, care or maternity, which were predominant in former eras (Rotundo 1993). The ‘sexy body’ is seen as the main, if not the only, attribute of a femininity. On the one hand, a sexual body is rendered as a female source of power; however, at the same time, it is seen as something that has to be subjected to external control, care and discipline, as well as change (e.g. through consumerism and expenditure), in order to meet the evergrowing demand for rigid and limited standards of female attractiveness. Women are the proper object of the male gaze, while disabled people are the proper object of the stare. Beauty contests, girlie shows, freak shows, telethons and medical theatre all testify to an appropriating to-be-looked-atness that supposedly inheres in the female and or the disabled body. Leering at women and gawking at disabled people are historical practices that constitute female and disabled personhood in the social world (Thomson 2001). According to Gill (2007), reporting on women’s bodies constitutes one of the largest parts of all content covered by media of various genres. Bodies are constructed as a ‘window into the inner life’ and as an essence of a woman and are examined, as well as critically reflected upon by both men and women themselves. In this sense, a woman with disability is treated as unfeminine having a double curse. They are perceived as helpless, asexual, unsuitable for maternity and pushed away from traditional female roles as wives, housewives or mothers, in the predominant discourse (McDonald et al. 2007; Fine and Asch 1988; Morris 1991). Mehrotra (2006) through her ethnographic research in Haryana illustrates how marriage and motherhood prospects of disabled women are marred by physical disabilities, as society views such persons as incomplete. They are perceived to be in need of care themselves and as being unable to fulfil a caring mothering role. Such women may be married off to ‘wrong’ persons or those who are already married, as they are construed as burden on the family. They are more likely to be divorced or abandoned than normal women. Meekosha (2005) puts together the gender differentials with respect to disabled women: Poverty hits harder on women and girls due to patriarchal property ownership structures; aid is less likely to reach women and girls who are less able to compete in situations of scarcity; disabled women are more vulnerable to domestic violence; disabled girls are likely to find

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their access to education even more limited than girls in general; women disabled by war have few resources to survive; disabled women who are sexually abused are likely to have few if any social supports or options, and; disabled women are less likely to be accepted as refugees by industrially-advanced countries.

Feminist theory has given considerable attention to the necessity for confronting existential questions—the void, the dark centre of the self—and to recognizing the complex emotions surrounding female subordination. Wright (1960) has suggested that we impose mourning on disabled people as a defence of our own values. Gilligan (1982) points out that this premise is basic to the ethic of justice that characterizes the highest value in masculine morality, but women’s morality places a higher value on an ethic of care, whose premise is that no one should be hurt. Cultures sustain the social relations of gendered disability in constant reiterations of stereotypes and expectations. Gender stereotypes interact with disability stereotypes to constitute a deep matrix of gendered disability in every culture, developed within specific historical contexts, and affecting those contexts over time. While language is the most analysed site for the examination of both gender (Connell 2002) and disability (Corker and French 1999), they interact in many other cultural locations—such as cinema, television, fiction, clothing, ‘body language’ and gesture. Gender distinctions also continue in the labour market and also at the workplace as highlighted by Pettinicchio and Maroto (2017). The experiences of working women with disabilities powerfully illustrate the continuing significance of status hierarchies within the workplace. Attaining employment appears to be particularly difficult for women with disabilities; they are less likely to be employed than men with or without disabilities and women without disabilities and also face wage discrimination as against the male counterparts (Brown and Moloney 2018). Their rights as workers may be overlooked and may be forced to endure oppressive working conditions (Rao 2004). Gender and disability indeed create multiple layers of discrimination which impact the mental health.

Women with Disabilities and Mental Health Gendered analysis of disability creates a distinct account of the impact on the gendered psyche of disabling social relations. Psychological models of individual development are increasingly taking account of gender formation. As the psyche takes form, the process of identity formation that develops through process of interaction with others contains a deeply embedded set of responses geared to the hierarchies of value in the able-bodied world. The identities that coalesce are thus both gendered and embodied, affected by the hormonal changes of growth and the social influences from role expectations, peer groups, family and the wider society. For people with impairments, the reading of them from significant others and the wider society combines with the gendered nature of relations to differentiate them from the ‘normal’ world. For instance, disabled girls may have their desires to be mothers supported by their gender role expectations but simultaneously denied by their disability status, thereby

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widely seen to be unfit mothers, deviant and alternatively asexual or dangerously promiscuous (Jana 2008). Thus, the situation of women with disabilities is more fraught as they suffer the double burden of gender and disability-based oppression (Addlakha 2009). Importantly, their struggle to express the feelings of being disabled and the effect of the same in their mental condition poses a big question in front of the society. Such situations demand more inclusion and sensitivity in general. In fact, as Wendell (1989) highlights, ‘feminists also grapple with issues that disabled people also face in a different context’. Some of the multifaceted issues faced by women with disabilities are as follows: Stigma: To have a disability is not only a physical or mental condition; it is also a social and stigmatized one (Goffman 1963). Gender-biased norms, such as the acceptance of disabled men being able to marry, but not disabled women, create stigma within the home. Notions of discrimination are felt throughout all realms of life, but their birth in the home creates a severe form of social isolation (Humphrey 2016). There is overlooking of their intellectual capacities, rejection of their feelings, choices and aspirations. The stigma indeed impacts their day to day experiences, the concept of self, sense of overall well-being and mental health. Low Self-Concept: The feeling of being inferior and not being able to be a part of the mainstream society further impacts the chances of being affected mentally. Mehrotra (2006) explains how disabled women are humiliated and made to feel inferior with ridicules hurled at them and by people addressing them by terms like langdi (limb deformed) or kani and andhi, for the one-eyed and visually challenged; goongi and behri, for the deaf and dumb; and bholi and bawali, for the mentally challenged instead of their names. Since they are unable to meet the societal criterion for fulfilling the gendered expectations, this impacts their roles and significant relationships within the household, community and larger society which in turn affect their self-perception and confidence. Furthermore, disabled women suffer more than disabled men from the demand that people have ‘ideal’ bodies because in patriarchal culture people judge women more by their bodies than they do men (Wendell 1989). Reiterating gender differentials, Begum (1992) quotes Fine and Asch to describe how disability is experienced differently by men and women and the differences between self-identification for disabled men and women: Disabled women are not only more likely to internalize society’s rejection, but they are more likely than disabled men to identify themselves as ‘disabled’. The disabled male possesses a relatively positive self-image and is more likely to identify as ‘male’ rather than as ‘disabled’. The disabled woman appears to be more likely to introject society’s rejection and to identify as disabled.

Lack of Confidence about own body: Addlakha’s (2007) research with young urban college students in India with various physical disabilities examines how young disabled people conceptualize their bodies, sexuality and marriage. Disabled bodies do not fit the cultural ideal of the healthy, strong, independent and beautiful body, and therefore, they can ‘body shame’ themselves. Addlakha and Vaidya (2017) further argue that the physical appearance is so critical for a woman’s identity, a negative body image will necessarily result in developing a negative self-image undermining self-confidence and increasing the sense of worthlessness.

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Neglect and Exclusion: It has been seen that in most of the Indian families, disabled women, girls are kept hidden at home and are denied basic rights such as of education, mobility and employment. Addlakha and Vaidya (2017) emphasize that women with disabilities are also considered as financial burden and social liability by their families; they are viewed as asexual, helpless and dependent; their vulnerability to physical, sexual and emotional abuse is enormous; their aspirations for marriage and parenthood often denied; they grow up ensconced within the walls of home or special institutions isolated and neglected with no hope of a normal life. Such a situation ultimately leads to the bad effect on their mental health in the long term. Ego defences: The impact of neglect and exclusion on mental health of differently abled women is reiterated by Sumskiene et al. (2016). They argue that being present together at the same time the aspects of disability and gender hinder the person’s positive self-concept significantly. Their research reflects the adoption of ego defence mechanisms by many women as they do not fit into to the normative requirements of femininity, i.e. to be pretty, lovely or to start a family and have children due to which they may become frustrated and sad and start defending themselves through alternative methods such as sarcastic remarks. But on the whole, the ‘norm’ of femininity and especially the order of gender remain unchallenged. They quote verbatims from their field-based research: “And would you imagine, a beautiful, wonderful, great woman all of a sudden becomes disabled…” (Audra). Disability turns self-concept based on gender into something that could be described as a metaphor of a ‘dotted line’. For example, some practices that symbolise femininity are reproduced: “If I’m going out, I do still want to put make up on and dress up nicely” (Marija); others are perceived as barriers: “You can always change something, because I wouldn’t live in a tent, maybe I could try but I am a lady so… Somehow I find it awkward to go into this adventure” (Dana) (as cited in Sumskiene et al. 2016, p. 23).

Ironically, the interaction of stereotypes can generate resistance which consists of an embracing of stereotypes—for example, disabled women may be perceived as inappropriate mothers and only have status as receivers of care by others, so their resistance may consist of asserting a desire for a traditional female carer role in relation to their own children (Grue and Tafjord Laerum 2002). Disabled men who are not able to behave in stereotypically competitive masculine ways may adopt a variety of strategies to cope with the stigma they experience from others. Such responses include redefining masculinity as financial autonomy rather than physical prowess; building physical strength in areas of physical capacity (the ‘supercrip’ phenomenon) or creating alternative masculine identities that stress personhood rather than gender roles (Gerschick and Miller 1994). Riessman-Kohler (2003) examines masculinity and multiple sclerosis and points to the break-down of traditional marriage relationships when partners cannot cope with the disease state. She reflects on the importance of moving beyond the analytical binary of male/female sexual identities. She also reveals the analytical binary of able-bodied/disabled, which she argues can force descriptions of experiences into either/or categories, rather than allowing sensitivity to a complex range of responses and attitudes. When some men find themselves unable to perform masculine roles

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(including employment) and resent their decreasing capacity to be independent, selfsufficient and self-determining, they explore their sexuality and widen their definition of gender identity to include more feminine and bi-sexual components (RiessmanKohler 2003). Mental illness: Being subject to constant staring, condescension, pity and hostility in the public gaze, rejection by own family, denial of basic respect and dignity makes them vulnerable to develop mental illness. There is ample evidence that women with disabilities experience major psychosocial problems that remain largely neglected including depression, stress, lowered self-esteem and social isolation (Nosek and Hughes 2003). Disabled women are often left out of community efforts that demand physical or mental strength because of such culturally legitimized representations that depict them as inadequate and expendable. The foresaid factors create a risk for the overall sense of well-being, sense of worth and positive mental health as they are unable to get an opportunity to realize own potentials.

Looking Ahead There is a need for multipronged initiatives to delve deeper into understanding the discourse of feminist disability and to address core issues, both, as a part of feminist disability research, as well as feminist research, in general. The projection of women with disabilities as inferior, dependent and asexual beings essentially violates all human right norms, wherein the emphasis on imperfection of the body not only condones denial of rights over their own bodies but legalizes socially sanctioned abuses such as the denial of basic dignity as an individual, to receive love and care, adequate mental and physical health care, marriage and motherhood.

References Addlakha, R. (2007). Gender, subjectivity and sexual identity: How young people with disabilities conceptualise the body, sex and marriage in urban India. Occasional Paper, CWDS, New Delhi. Addlakha, R. (2009). Gender, subjectivity and sexual identity: How young people with disabilities conceptualise the body, sex and marriage in urban India. Working Papers, Centre for Women’s Development Studies, New Delhi. Addlakha, R. (2017). Disabled masculinity. MWG 001: Women and disability (pp. 123–127). IGNOU. Retrieved from http://egyankosh.ac.in/bitstream/123456789/40702/1/Unit-3.pdf Addlakha, R., & Vaidya, S. (2017). Unit-5, disability and feminism. IGNOU. Retrieved from http:// www.egyankosh.ac.in/bitstream/123456789/3218/1/Unit-5%20.pdf Anand, M. (2014). Gender and education: Challenges and strategies. New Delhi: Regal Publications. Begum, N. (1992). Disabled women and the feminist agenda. Feminist Review, 40(1), 70–84. Brown, R. L., & Moloney, M. (2018). Intersectionality, work, and well-being: The effects of gender and disability. Gender and Society, 33(1), 94–122.

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Clark, B., & Mesch, J. (2016). A global perspective on disparity of gender and disability for deaf female athletes. Sport in Society, 21(1), 64–75. Connell, R. (2002). Gender. Cambridge: Polity. Corker, M., & French, S. (Eds.). (1999). Disability discourse. Buckingham: Open University Press. Davaki, K., et al. (2013). Discrimination generated by the intersection of gender and disability. Brussels: European Union. Davis, B. H. (1984). Women, disability, and feminism: Notes toward a new theory. Frontiers: A Journal of Women Studies, 8(1), 1–5. Fine, M., & Asch, A. (1988). Women with disabilities: Essays in psychology, culture, and politics. Philadelphia: Temple University Press. Garland-Thomson, R. (1997). Extraordinary bodies: Figuring physical disability in American culture and literature. New York: Columbia University Press. Garland-Thomson, R. (2001). Reshaping, re-thinking, re-defining feminist disability studies. Washington, DC: Center for Women Policy Studies. Garland-Thomson, R. (2011). Misfits: A feminist materialist disability concept. Hypatia A Journal of Feminist Philosophy, 26(3), 591–609. Retrieved from https://www.researchgate.net/publication/ 230311251_Misfits_A_Feminist_Materialist_Disability_Concept. Gerschick, T., & Miller, A. (1994). Gender identities at the crossroads of masculinity and physical disability. Masculinities, 2(1), 34–55. Gill, R. (2007). Postfeminist media culture: Elements of a sensibility. European Journal of Cultural Studies, 10(2), 147–166. Gilligan, C. (1982). In a different voice: Psychological theory and women’s development. Cambridge, MA: Harvard Univ. Press. Goffman, E. (1963). Stigma: Notes on the management of spoiled identity. New York: Touchstone. Goodley, D. (2011). Disability studies: An interdisciplinary introduction. Los Angeles, CA: Sage. Grue, L., & Tafjord Laerum, K. (2002). ‘Doing Motherhood’: Some experiences of mothers with physical disabilities. Disability and Society, 17(6), 671–683. Humphrey, M. (2016). The intersectionality of poverty, disability, and gender as a framework to understand violence against women with disabilities: A case study of South Africa. Jana, G. (2008). Sterilization in Alberta, 1928 to 1972: Gender Matters. Canadian Review of Sociology, 45(3), 247–266. Kim, M. Y. (2013). Women with disabilities: The convention through the prism of gender. In M. Sabatello & M. Schulze (Eds.), Human rights and disability advocacy (pp. 113–130). Philadelphia, PA: University of Pennsylvania. Lloyd, M. (1992). Does she boil eggs? Towards a feminist model of disability. Disability, Handicap and Society, 7, 207–221. Lonsdale, S. (1990). Women and disability: The experience of physical disability among women. London: Macmillan. McDonald, K., Keys, C., & Balcazar, F. (2007). Disability, race/ethnicity and gender: Themes of cultural oppression, acts of individual resistance. American Journal of Community Psychology, 39, 1–2. Meekosha, H. (2005). Encyclopaedia of disability. Thousand Oaks, CA: Sage Publications, Inc. Mehrotra, N. (2006). Negotiating gender and disability in rural Haryana. Sociological Bulletin, 55(3), 406–426. Morris, J. (1991). Pride against prejudice. London: Women’s Press. Morris, J. (1992). Personal and political: A feminist perspective on researching physical disability. Disability, Handicap & Society, 7(2), 157–166. Nosek, M. A., & Hughes, R. B. (2003). Psychosocial issues of women with physical disabilities: The continuing gender debate. Rehabilitation Counseling Bulletin, 46(4), 224. Pettinicchio, D., & Maroto, M. (2017). How gender and disability status intersect to shape labor market outcomes. Research in Social Science and Disability, 10(3), 33. Rao, I. (2004). Equity to women with disabilities in India. Bangalore: CBR Network.

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Riessman-Kohler, C. (2003). Performing identities in illness narrative: Masculinity and multiple sclerosis. Qualitative Research, 3(1), 5–33. Rotundo, E. A. (1993). American manhood: Transformations in masculinity from the revolution to the modern era. New York: Basic Books. Shakespeare, T., & Watson, N. (2001). The social model of disability: an outdated ideology? In S. Barnarrt & B. M. Altman (Eds.), Exploring Theories and Expanding Methodologies: Where are we and where do we need to go? Research in social science and disability (Vol. 2). Amsterdam: JAI. Shakespeare, T. W. (1994). Cultural representations of disabled people: Dustbins for disavowal? Disability and Society, 9(3), 283–299. Sumskiene, E., Jankauskaite, M., & Grigaite, U. (2016). Intersection between a social gender and disability: A self-concept of women with disabilities in the post-feminist context. Considering Disability, 1(3&4). Thomson, R. G. (2001). Re-shaping, re-thinking, re-defining: Feminist disability studies. Barbara Waxman Fiduccia Papers on Women and Girls with Disabilities. Washington: Center for Women Policy Studies. Retrieved from https://www.womenenabled.org/pdfs/Garland-Thomson,Rosema rie,RedefiningFeministDisabilitiesStudiesCWPR2001.pdf Waxman, B. F., & Wolfe, L. R. (1999). Introduction to women and girls with disabilities: Defining the issues – an overview. Center for women policy studies. Wendell, S. (1989). Toward a feminist theory of disability. Hypatia. Feminist Ethics & Medicine, 4(2), 104–124. World Health Organization. (2002). The international classification of functioning disability and health. Geneva: WHO Press. World Health Organization and World Bank. (2011). World report on disability. Geneva: World Health Organization. World Health Organisation. (2014). Social determinants of mental health. Geneva, Switzerland: World Health Organization. Wright, B. (1960). Physical disability—A psychological approach. New York: Harper & Row.

Chapter 8

Gender and Schizophrenia: Are Differences Biological or Social? Ananya Mahapatra and Smita N. Deshpande

Introduction Gender is one of the most important social determinants of health and exerts significant influence on the onset, manifestation, course and outcome of mental disorders (Tamminga 1997). The differences between men and women as to social position, access to healthcare and other resources determines their ‘susceptibility and exposure to mental health risks’ and decides the effect of health policy and public health endeavours on their lives (World Health Organization 2001). Gender does not indicate ‘sex’. While sex refers to a distinct cluster of biological attributes associated with physiological parameters such as chromosomes, gene expression, hormone function and reproductive/sexual anatomy (Coen and Banister 2012), gender is more concerned with socially constructed roles and identities which influences the way people perceive themselves and others, their patterns of behaviour and interaction as well as the distribution of power and resources in society. However, interaction between biologically determined sex and largely socially determined gender influences health and well-being in a variety of ways. Both impact degree of exposure to environmental and occupational risks, extent of risk-taking behaviours, access to health care, health-seeking behaviour, healthcare utilization, and perceived experience with health care and thus disease prevalence and treatment outcome (Canuso and Pandina 2007). Schizophrenia (SZ) is a common but highly disabling disorder. The median population period prevalence of SZ is around 3.3 per 1000 worldwide (Saha et al. 2005). The National Mental Health Survey of India (NMHS-2017) reported the lifetime prevalence of severe mental disorders such as schizophrenia, other non-affective psychoses and bipolar affective disorder as 1.9% with point prevalence of 0.8% A. Mahapatra · S. N. Deshpande (B) Department of Psychiatry, Centre of Excellence in Mental Health, ABVIMS-Dr RML Hospital, New Delhi 110001, India e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2020 M. Anand (ed.), Gender and Mental Health, https://doi.org/10.1007/978-981-15-5393-6_8

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(Murthy 2017), thus highlighting its chronicity. Worldwide, SZ is associated with a chronic debilitating course, poor recovery, high rates of comorbid physical illnesses, increased mortality and significant socio-economic burden (Charlson et al. 2018). Both gender- and sex-related determinants for this disorder have been widely investigated and reported. This chapter focuses on SZ as a prototype for demonstrating how gender and sex determine various aspects of the illness, focusing as far as possible on the Indian scenario.

Prevalence and Risk Systematic reviews of epidemiological studies have not found a difference in prevalence of SZ among males and females (Charlson et al. 2018). The NMHS, conducted across 12 states of India, also found the gender prevalence of psychotic disorders to be near similar (lifetime prevalence—male: female—1.5%:1.3%; current prevalence: male: female—0.5%:0.4%) in accordance with previous findings (Murthy 2017). Nevertheless, several gender-specific differences have been reported in illness-related parameters such as onset, clinical presentation and course across cultures (Lewine 2004), while others, especially in India, have refuted this claim (Thara and Kamath 2015). There is probably no difference in the incidence of SZ in India among men and women (Thara and Kamath 2015). While SZ may begin at any age, earlier claims that at younger ages, male sex is a risk factor for schizophrenia, but beyond 40 years of age, women have a higher risk of developing the disorder may not be accurate (Aleman et al. 2003). A meta-analysis of 38 higher quality studies in the same paper reported the overall risk ratio for SZ among men as compared to women to be 1.39 (Aleman et al. 2003). Relatives of women with SZ may be at higher risk of the disorder than relatives of men with SZ (Goldstein et al. 1992). Relatives of SZ patients are, in general, at a higher risk to develop the disorder than the general population. Risk increases with the closeness of the relationship and is highest for children with both parents with SZ and among identical twins (Kendall et al. 2010). The risk is conferred either by rare alleles (i.e. variant form of a gene) of large effect and/or multiple common alleles of small effect. Most studies of risk are based on Western Caucasian populations. As yet, calculation of genetic risk of SZ among family members of Indians with SZ has not been conducted due to the complex logistics involved. All members of the family up to second-degree relatives need to be followed up throughout the age of risk, which extends to practically the entire lifespan. Due to lack of concrete data, it is difficult to advise relatives about their risk of developing the disorder and to impart genetic counselling in India. Only one retrospective, experimental study has been published from India, to our knowledge (Bhatia et al. 2016). Its results have not been replicated.

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Age of Onset A major WHO 10-country study reported an earlier age of onset in males (Jablensky et al. 1992). The Determinants of Outcome of Severe Mental Disorders (DOSMeD) study conducted by the WHO found a consistent difference in age of onset across countries from developed to developing, perhaps due to biological factors (Hambrecht et al. 1992; Varma and Malhotra 2007). The difference in age of onset observed in many centres of the WHO studies reported an average difference of 3.5 to 6 years (Häfner et al. 1989), and women had a second ‘peak’ above age 40, in developed countries (Hambrecht et al. 1992). A subsequent meta-analysis of 46 studies investigating gender differences in the age of onset for SZ reported a pooled estimate of gender difference of only 1.07 years (95% confidence interval 0.21–1.93) for age at first admission of schizophrenia, with males having earlier onset (Eranti et al. 2013). No differences were observed between developed and developing countries. The gender difference in age of onset has been shown to be much less than previously reported, perhaps due to social factors (almost all studies have been hospital-based). Even as early as the DOSMeD study, authors speculated that this could be due to fewer women seeking help (Hambrecht et al. 1992).

Clinical Manifestation, Course and Outcome More substantive differences in clinical features, particularly severity, have been documented. From a retrospective review of studies from 1966–1999, women with SZ reported affective symptoms, auditory hallucinations and persecutory delusions more frequently, with lower prevalence of smoking and substance abuse, while males reported more negative symptoms and cognitive deficits (Leung and Chue 2000). The lower prevalence of smoking and substance abuse among women may clearly be due to social availability and acceptability as both rates are rising in women all over the world (Greenfield et al. 2010). There is substantial evidence that men with SZ suffer a more severe form of the illness and a more malignant course than women (Lindamer et al. 2003). Women with SZ show significantly better social function (Angermeyer, Kühn, and Goldstein 1990). A systematic meta-analysis of 23 studies detected a highly significant association between male sex and ‘deficit schizophrenia’ [pooled odds ratio (OR) = 1.75] (Roy et al. 2001). Deficit SZ was defined as the presence of at least two out of six ‘negative’ symptoms for at least 12 months, not due to any other disorder. ‘Negative’ symptoms, as the name suggests, are a ‘lack’—less emotional reactivity seen as blunted affect, lesser speech (alogia), asociality, lack of motivation (avolition) and lack of ability to feel pleasure (anhedonia) (Lincoln et al. 2017). Women with SZ may have a less deteriorating course of illness. A 14-year follow up study from rural China reported that compared with female participants, male

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participants were significantly younger, had significantly higher rates of mortality, suicide and homelessness, and poorer family and social support (Ran et al. 2015). In this study, the authors found no significant gender difference in clinical symptom scores on a widely accepted scale (Positive and Negative Syndrome Scale), previous suicide attempts, previous hospital admission or inability to work (Ran et al. 2015). A similar conclusion has been reported for Indian women too (Thara and Kamath 2015), but it is unclear if this is due to lower expectations from women. Most women participants in research studies are housewives and receive support at home in their occupational role (Srinivasan and Thara 1999). Not all studies have consistently reported a more severe form of illness among men. A ten-year follow up of 141 first admitted SZ and schizophreniform (a form of SZ of shorter duration at presentation) patients reported no significant difference between men and women in clinical outcome (Opjordsmoen 1991). Other conflicting results have also been reported. These differences likely reflect the heterogeneity of presentation of SZ, sample size variation and even subtle diagnostic differences. In India, outcomes seemed to average out to an ‘intermediate’ outcome over ten years (Cohen et al. 2008). Thomas et al. in 2010 analysed differences in clinical variables among men and women in two large independent samples, one recruited from the USA and another from Delhi (Thomas et al. 2010). Among the patient sample from the USA, SZ was the more frequent diagnosis among men (66.6%). Among women, SZ and schizoaffective disorder were diagnosed more evenly (50.8% vs. 49.2%). The majority of male patients did not have children (77.8%), while proportionately more women (47.5%) had one or more children. Cannabis abuse was more common among men (73.6%) than women (58.2%). Men were more likely to be unmarried (79.2% vs. 56.7%). Women were more likely to report the presence of thyroid or other hormonal disorders (male: female—9%:24.8%) or migraine headaches (male: female—15.3%:34.6%). In the Indian sample, drug or alcohol consumption was more common among men than women. Women more frequently ‘showed emotions that did not fit for what was going on’ (men: women—42.2%:54.9%). Compared to women, more men were categorized as having continuous chronic illness with deterioration. A comparison of the USA and Indian samples in post hoc analysis demonstrated that gender was an important predictor for the following variables—course of illness, marital status and number of living children. There was no significant difference between the two samples for other clinical manifestations, highlighting that gender-based differences in clinical presentation of SZ and related disorders are possibly due to biological rather than socio-cultural factors (Thomas et al. 2010). Suicide attempts and self-harm behaviour have been demonstrated in one-fourth of SZ patients. A study conducted at RML hospital in 2015–16 retrospectively investigated the factors associated with risk of deliberate self-harm and suicide among persons with schizophrenia. This study reported that among those who had ever attempted suicide over 60% were males (Jakhar et al. 2017). There are also differences in terms of prognosis, for example, women with SZ tend to have better outcomes in terms of clinical course and occupational and social functioning compared to men (Thara and Rajkumar 1992).

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Fertility and Reproduction Numerous studies in economically advanced European nations, as well as Japan and the USA, have reported on gender-related variations in procreation among individuals with SZ (Hutchinson et al. 1999). Very few Indian studies have examined the genderspecific differences in fertility and fecundity. Among Indian SZ patients, reduced fertility was observed in 100 individuals with SZ in comparison with their relatives, but gender-related effects were not examined in this study (Thara and Srinivasan 1997). A study (Bhatia et al. 2004) examined the indices of fertility and fecundity in an Indian (New Delhi) SZ sample compared to a US sample (Pittsburgh). There was no significant gender-based difference in marital fertility in India; i.e. among individuals who had ever been in conjugal relationships, male and female patients did not differ with respect to the number of children. However, the US male cases had significantly lower marital fertility. Indeed, the marital fertility rate was numerically larger among Indian men compared to Indian women. Consequently, none of the gender-based comparisons attained statistical significance in the Indian sample, unlike the US sample. However, Cohen et al. (2008), in the older DOSMed study, reported much lower rates of marriage in patients as compared to the general Indian population (Cohen et al. 2008), a fact echoed in the Bhatia et al. (2004) sample. These studies, however, have not been replicated in the changed social scenarios.

Issues in Treatment The physiological differences among men and women result in differences in pharmacokinetics and pharmacodynamics of psychotropic drugs essential for treatment of SZ. This has been postulated as one of the major reasons for gender-specific differences in treatment response as well as side-effect profile for psychotropic drugs in SZ (Usall et al. 2007). Neuroleptic-naive women show a better response to antipsychotic medication than neuroleptic-naive men and being male is associated with a reduced likelihood of response to antipsychotic treatment at 1 year compared to being female (Robinson et al. 1999). The Schizophrenia Outpatient Health Outcome (SOHO) study of 10,000 people in ten different European countries found that gender was a significant predictor of response to antipsychotic treatment with women responding better than men (Usall et al. 2007). Studies appear consistent across the world in finding that men are treated with larger doses of antipsychotics than women (Salokangas 2004). (Melkersson et al. 2001) found that men required twice the antipsychotic dose than women, which they ascribed to differences in metabolic clearance. Men were treated with higher doses of antipsychotics than women, and men had a worse treatment outcome compared to women (Tang et al. 2007). Studies on this issue are lacking in India.

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Coercive methods are sometimes used in treatment of SZ patients with potential risk of harm to self or others. Gender-based differences in patterns of coercive treatment have also been reported. Physical restraint was used more often with male patients, while forced medication and seclusion were used more often with female patients (Wynn 2002). Drug side effects, such as metabolic syndrome (leading to obesity and related illnesses such as diabetes), appear to be quite common in women on treatment with antipsychotics (Chandra et al. 2012). Box 8.1 Biological Differences among Men and Women with SZ • Major differences between prevalence and incidence of schizophrenia amongst men and women have not been reported. • Risk-ratio of developing schizophrenia is slightly higher in men compared to women in the best studies. • Earlier age of onset is reported in men while women may have a second peak of onset later on in life. • Women are said to have a slightly better course of illness than men. • Physiological differences among men and women affect medication doses. Take Home: While a few gender-related differences may exist in the biological parameters related to schizophrenia, they are not pronounced and may be influenced by social factors.

Disability and Quality of Life Women were more disabled than men with a strong correlation between negative symptoms and disability variables in both the sexes, among 30 people with SZ living with their spouses (Shankar et al. 1995). Men reported more disability in terms of occupational functioning (Thara and Joseph 1995). Women, on the other hand, reported more disability in terms of marital and family functioning (Thara and Srinivasan 1997). These differences are also reflective of the distinct gender-based societal roles of men and women in traditional societies such as ours, where men are expected to be employed and earn a livelihood, whereas women are entrusted with household and family responsibilities where they may get support. Gender roles for men and women direct them along different life trajectories which determine the parameters of optimal functioning. Women with SZ have a poorer quality of life, with higher disability (Kujur et al. 2010). But in a five year follow up study of first episode SZ (Johnson et al. 2014) authors found no differences in disability scores among men and women since

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disability depended as much on social (availability of opportunities, enabling environment, lesser stigma) as biological (type of symptoms, course of illness, insight) factors. In a study from rural Southern India, Suresh et al. (2012) reported good occupational outcome in 2/3rd of their sample, with poor outcome associated with male gender, longer duration of illness, higher psychopathology and poor treatment adherence (Suresh et al. 2012). In a large survey from Delhi, Trani et al. (2015) found that being a woman and being from a lower caste predicted likelihood of poverty (Trani et al. 2015). Two major Indian laws (Persons with Disability Act 1995 and Rights of Persons with Disabilities Act 2016) have acted as enablers for person with mental disabilities. Several Indian publications studied the rates of disability certification among men and women. It would be expected that these would be similar, given the minor differences in the disorder (Persons with Disability Act 1995; Rights of Persons with Disabilities Act 2016). Using the Indian Disability Evaluation and Assessment Scale (IDEAS—a scale developed for disability certification by the Indian Psychiatric Society with good psychometric properties) (Grover et al. 2014), Balhara et al. reported that the total IDEAS score for men was significantly higher than for women at a tertiary care centre in Delhi, especially for ‘self-care’ and interpersonal activities items of the scale (Balhara et al. 2011). Among disability certificate seekers, men had higher disability compared to women over a three-year period in Mangalore, Karnataka (Kashyap et al. 2012). In India, it appears that fewer women seek disability certification, and among those people with SZ who do, men are the more disabled. Only one study, to our knowledge, reported opposite results (Kujur et al. 2010). Initiation and continuation of antipsychotic medications together with psychosocial interventions may be associated with lesser disability (Thirthalli and Kumar 2012). Over five years at RML Hospital, fewer women sought disability certification than men (Balhara et al. 2013). Box 8.2 Government Entitlements under of Disability Certification* • Income tax deduction under Section 80U • Disability pension for Below Poverty Line Persons with Disability (PwD) • Train concession for PWD, accompanying caregiver up to 75% • 4% quota in government jobs • Right to inclusive education • Various concessions by Education Boards • Punishment for discrimination against disabled *Are enhanced from time to time Intangible Benefits • Feeling that one is not alone • Reduces stigma • Can form advocacy groups

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• Can fight for their rights • Number of people disabled by a particular disorder is measured. Cross-national surveys conducted in the USA and Canada found equivocal genderrelated differences in quality of life (Vandiver 1998). Besides illness-related factors, quality of life may be more directly related to an individual’s social circumstances which are, in turn, contingent on various gender-specific factors. Gender is therefore one of the key mediating factors which interacts with clinical, social and cultural factors determining psychological distress, level of functioning and quality of life for patients of SZ and related disorders. With changing times and consequent changes in social structure, socio-cultural norms and empowerment of women, the structure of socially determined gender roles is also changing (Lopez-Claros and Zahidi 2005). Increased opportunities for education, employment, financial stability and general improvement in quality of life of women, it is hoped, will translate into improved quality of life in women who suffer from SZ. Improved access to healthcare services and increased help-seeking for women patients leads to reduction of the gender gap in treatment and improves rates of recovery and better functional outcomes for men and women patients in equal measures (Kermode et al. 2007).

Marriage It has been noted consistently from developed countries that the unmarried state and childlessness are more common among male patients of SZ and related disorders (Hutchinson et al. 1999). Fewer men with SZ in India get married, there are higher rates of divorce among women who do get married, and relapses are more common with never married people (although it is not clear if this was due to negative emotional interactions with their caregivers) (Avasthi and Singh 2004; Thara and Srinivasan 1997). Since marital trends are strongly linked to cultural practices and overall sociocultural milieu of a population, differences may exist among developed and developing nations. To examine this hypothesis, a study comparing a US sample with an Indian sample of SZ reported that while there were no significant differences in marital status among men and women in India, men in the US sample were much less likely to have established conjugal relationships (Bhatia et al. 2004). The proportion of individuals who were childless also did not differ by gender in India. But in the US sample, the male patients had significantly fewer children compared to their female counterparts (Bhatia et al. 2004). When the history of conjugal relationships was compared among Indian and US samples, it was found that approximately 40% of male Indian patients and 50% of Indian women patients had ever been in conjugal

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relationships. In contrast, in the US sample, only 20% of male US cases reported having been in such relationships, compared to 40% of US women. The increased likelihood of male patients from India to be married is possibly reflective of the cultural practices prevalent in the society, such as elevated marriage rates (Bloom and Reddy 1986). Among 200 persons with SZ, men reported being unmarried, while women reported experiences of stigma in relation to marriage, pregnancy and childbirth (Loganathan and Murthy 2011) and even menopause (Thara and Kamath 2015). The law discriminates against women with mental illness (Sharma et al. 2015). In a ten-year follow-up study, more marriages broke up for women than men especially where there were no children (Thara and Srinivasan 1997). Women whose marriages did not survive were ‘doubly disadvantaged’—many did not get legally separated and received no maintenance (Thara et al. 2003). However, as compared to western countries, data on stability of marriage was more favourable in India in another study. Fifteen years after the original International Study on Schizophrenia (ISoS), other countries’ rates of marriage were 48% for women, 28% for men, while in India, rates were 74% for women and 71% for men (Hopper et al. 2007). But even with surviving marriages, women with SZ reported a poorer quality of marriage (Aggarwal et al. 2019), leading to poorer sexual functioning (Simiyon et al. 2016).

Parenting Parenting, one of the vital aspects of familial functioning, is seriously affected in families with a parent with SZ. The long-standing nature of the illness and its psychopathology may make it difficult for the person with SZ to deal with challenges of parenting (Abel et al. 2005). Gender-based differences in parenting styles of SZ mothers were vilified in the past as schizophrenogenic, but no more. The specific parenting challenges and experiences that mothers with SZ face require constant guidance and counselling (Solari et al. 2009). Parenting in men with SZ has been scarcely explored by clinical or social scientists. Second-order theory of mind deficits may specifically impair parental role functioning (Mehta et al. 2014). But in a study from Bangalore, 70% of children were satisfied with the parenting they received from their one SZ parent, especially when there was a good ‘other’ social support system (Herbert et al. 2013). The pregnancy rates of mothers with SZ do not differ significantly from those of the general population (Miller 1997). However, mothers’ severe mental illness, combined with poor social support and comorbidity, may significantly affect her parenting capacity (Riordan et al. 1999). The offspring of women with SZ has been shown to be vulnerable to stress in early rearing environment, poor relationship with both parents, poor verbal communication and lifetime emotional, behavioural and cognitive difficulties and increased risk of developing psychiatric disorders in later life (Arvaniti et al. 2012). Mothers with

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SZ had more complex clinical and psychosocial problems and experienced poor parenting outcomes in a longitudinal cohort study (Abel et al. 2005). Those mothers who had a supportive family environment, non-affected partner and higher socio-economic status had better parenting outcome (Abel et al. 2005). It is therefore essential to understand that improving psychosocial circumstances can mitigate the adverse effect of the illness on a mother’s parenting capacity and potentially reduce the adverse outcomes for the offspring.

Stigma Stigma is defined as ‘an attribute that is deeply discrediting’ that reduces the bearer ‘from a whole and usual person to a tainted, discounted one’ (Goffman 1963). The stigma of mental illness needs to be studied within its socio-cultural context in order to understand its origins, meaning and consequences. Gender is one of the key factors influencing stigma. A qualitative study conducted on 200 patients from both rural and urban backgrounds, to assess the patterns of stigma and the disadvantages created by it, found that on the whole, men in the study experienced shame and ridiculing, difficulties in getting married, hid their illness from others and in their job applications and worried what others may think of them (Thara and Srinivasan 2000). Men were stigmatized mostly in relation to their occupations, both at their place of employment and if they were unable to become employed, while women were mostly stigmatized within the family. Even caregivers reported higher stigma for women affected with SZ (Thara and Srinivasan 2000). Stigma of mental illness is also associated with other adverse psychosocial consequences in patients of SZ such as multidimensional poverty and social exclusion (Trani et al. 2015). Effective ‘allopathic’ care helps alleviate stigma (Raguram et al. 2004). In a nationwide multicentric study, persons with SZ, especially women, experienced higher degree of stigma on a stigma scale in the domains of alienation, stereotype endorsement, discrimination and social exclusion than persons with two other major mental disorders (Grover et al. 2017). Those who functioned at a lower level than average experienced greater stigma, while knowledge about the illness may help reduce stigma (Singh et al. 2016a). Patients have been shown to internalize the stigma as well (Singh et al. 2016a). Caregivers of persons with SZ also face stigma (Koschorke et al. 2017; Singh et al. 2016b). Psychoeducation, specific services and programs should be devised and implemented for caregivers too. Even postgraduate medical students, who are not well trained in psychiatry, express stigma towards patients with SZ (Chandramouleeswaran et al. 2017).

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Caregiver Burden While gender-differences in patient-related parameters have been widely researched upon, the differential role of gender in experiencing caregiver burden as well as the impact of gender on caregiving is an area which warrants more inquiry. A study conducted in a tertiary care hospital from North India to evaluate the direct, indirect and intangible cost of chronic major mental illnesses to family and patients found the majority of the caregivers of patients to be females and of older age (Sharma et al. 2006)—old mothers or ageing wives of the patients (Deshpande 2005). Women spend more time in providing care and carry out personal care tasks more often than men and subsequently experience greater mental and physical strain, greater caregiver burden and higher levels of psychological distress while providing care (Sharma et al. 2016). Two systematic reviews on caregiver burden in SZ consistently reported that the majority of caregivers were usually women (mothers, followed by spouses, and sisters) (Awad and Voruganti 2008; Caqueo-Urízar et al. 2014), and such trends have been observed worldwide in developed as well as developing countries. While several studies have reported higher levels of caregiver burden, psychological stress, burnout and poorer quality of life among women caregivers of patients with SZ, others reported little or no gender-based difference, leading to a lack of a conclusive opinion on this subject (Sharma et al. 2016). Wives experienced significantly greater total burden and burden in the areas of external support, caregivers’ routine, patients’ support, patients’ behaviour and caregivers’ coping strategies (Kumar and Mohanty 2007). They were also more anxious, experienced more fatigue, frustration and feeling of isolation. Spousal burden may be reduced by decreasing the patient’s disability (Arun et al. 2018). However, another study of parent couples of a person with SZ reported that men and women were equally vulnerable to caregiving stressors (Ghosh and Greenberg 2012). Factors that may lead to perceived increased burden of caregiving are—among others—duration of illness, perceived social support, type and degree of psychopathology and disability (Jagannathan et al. 2014). Adaptive caregiving strategies led to a more positive outlook on caregiving (Doval et al. 2018). Structured interventions targeting caregivers have been shown to alleviate their distress and reduce disability. For example, structured psychoeducation interventions have been shown to reduce disability and burden in caregivers and improve coping as well as levels of satisfaction (Kulhara et al. 2009).

Gender-Based Violence While violence and aggression have been viewed as a part of clinical symptoms in SZ patients, but in reality, patients with SZ comprise a group which is more prone to be subjected to violent victimization themselves (Kooyman et al. 2007). Young age, comorbid substance use and homelessness are the major risk factors for victimization (Latalova et al. 2014).

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Gender-based disparities have been reported with respect to the type of victimization, but the evidence is yet inconclusive. A multicentre US study reported that women are more likely to report being beaten (Lam and Rosenheck 1998). Sexual assault was more frequently reported in women, and younger age was associated with sexual, but not other types of victimization (Lam and Rosenheck 1998). Contrarily, a second study reported that being male and being younger than 25 years was significantly associated with violent victimization (Silver 2002). Women with SZ have also been found to be more vulnerable to intimate partner violence (Goodman et al. 2001). Intimate partner violence has been defined as ‘any behaviour within an intimate relationship that causes physical, sexual or psychological harm’ (Dahlberg and Krug 2006). The definition includes a cluster of behaviours such as physical aggression, emotional and psychological abuse and sexual violence and coercion. Various studies have reported that female patients of SZ and other severe mental disorders are more likely to be victims of intimate partner violence (Goodman et al. 1997). A hospital-based study from South India of female in-patients with severe mental illness found that 30% had experienced sexual coercion in their lifetime (Chandra et al. 2003). A qualitative study in women with severe mental disorder who had experienced sexual coercion found that in 48% of the cases, the perpetrator was the spouse, and most of the incidents occurred in home environment (Thara et al. 2003). The chronic, debilitating, disorganizing effect of the disease, the social stigmatization and the overrepresentation among the low-income groups are some of the inherent factors that make these women particularly vulnerable to abusive and violent intimate relationships. Box 8.3 Key points: Social Differences among Men and Women with Schizophrenia • Women have a higher level of disability and poorer quality of life. • Women have lower access to certification and consequent disability benefits. • Women experience higher degree of stigma. • Majority of caregivers are women (mothers, spouses). • Unmarried state and childlessness are higher in Western male patients. • Favourable outcome in marital stability of both men and women with SZ is reported in India. • Women with SZ have difficulty in parenting and child-rearing. • Women with SZ are more susceptible to intimate partner violence. Sexual assault is more frequently reported by women patients. Take Home: Women with SZ face greater social disadvantage compared to men. Time will tell if this improves with changes in social milieu and change in gender-roles.

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Need for Gender-Based Equity in Mental Health Research In health research involving human subjects, gender issues especially concerning women, as well as issues specific to women are not adequately represented (Coen and Banister 2012). Sex and gender differences are not given adequate importance in the research design, analysis and reporting of results (Heidari et al. 2016). This often leads to limitations in generalizability and clinical applicability of the results especially across diverse settings. More recent guidelines try to bridge the ‘gender gap’ in research. In India, Indian Council of Medical Research (ICMR) mandated the National Ethical Guidelines for Biomedical Research involving Human Participants (Mathur 2017), wherein the principle of gender sensitivity is emphasized. These guidelines have the force of law. Women in special situations such as pregnancy, lactation, those with poor access to healthcare or with poor decision-making capacity making them prone to exploitation are deemed vulnerable population and need special provisions search. But they must be included in research so that they are not deprived of its benefits, with special care to safeguard their privacy and confidentiality, dignity, rights, safety and well-being. During research, information deemed to be sensitive should be protected to avoid stigmatization and/or discrimination (e.g., HIV status; sexual orientation; genetic information or any other sensitive information). ICMR also prescribed that Ethics Committee (EC) should have adequate representation of age and gender.

Role of Social Workers A good social worker is aware of and facilitates the incorporation of the principles of social justice, self-determination and empowerment to help deliver equitable health care (Bland and Renouf 2001). Social workers can help the treating team to identify the patient’s social situations such as family context, social relationships, vocational interests and cultural norms. In this process, they are better equipped to identify gender-based differences or disadvantages which adversely affect quality of life and formulate strategies to alleviate them, by collaborating with the patient and family. Social workers can also explore in depth the social consequences of SZ on the person and her family. They must intervene with the treating team to reduce the impact of these consequences. Social workers should act as a bridge between patients and treatment facilities during crisis management and intervention. Social workers must address the challenges, burden and burnout of the caregivers and educate and empower them. By imparting education about the illness to patients and family members, they can help in dispelling myths and misconceptions prevalent in communities and address the issues of stigma and discrimination. Social workers should facilitate the formation of patient and caregiver support groups. They must facilitate effective communication and openness to empower and enhance their patient’s acceptance into general society. Social workers must help

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the patients and their families to access various helping agencies and enable them to avail the benefits available to them such as disability certification. Social workers can also help patients and family members to seek legal aid whenever necessary. Lastly, at a macro-level, social workers can inform mental health legislators and policy makers to address gender-based issues while formulating health services so that they benefit male and female patients equally. Box 8.4 Role of a Social Worker in Ensuring Gender Parity • Explore the patient’s social situation: socio-economic status, family structure, relationships, vocation, income, cultural norms, community values. • Identify gender-based issues specific to the patient. • Psycho-educate patient and family members about mental illness. • Dispel myths, misconceptions and false beliefs related to SZ which hinder treatment seeking. • Inform all about importance of treatment, treatment-options and avenues of help. • Address caregiver burden: explore family burden and relationships, improve communication, and facilitate coping. • Facilitate the formation and mobilisation of patient and caregiver support and advocacy groups. • Enable patient and family members to avail state-sponsored benefits: disability certification, legal aid and others. • Alleviate stigma and discrimination through information, communication and education. • Inform and lobby with legislators to incorporate principles of gender-parity in mental health schemes. Take Home: Social workers should identify social factors which lead to gender discrimination and adversely affect the course and outcome of mental illnesses. They should contribute to devise strategies to reduce disparities in treatment as well as in policy level.

Conclusion Gender is an important determinant which affects both biological as well as social factors associated with schizophrenia. While the influence of gender is not as pronounced on the biological aspects of the illness, it has been demonstrated to exert some impact on specific social parameters. As far as social consequences of this illness are concerned, women are at a greater disadvantage due to stigma, poorer access to healthcare services and disability benefits possibly reflecting existing gender norms in our society.

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Perhaps with changing social structures and gender roles, accompanied by improvement in education and empowerment of women, this situation is likely to change with time. Active interventions at health service and policy level can help to alleviate gender disparity in treatment seeking and thus improve the course and outcome of SZ in both men and women. Effective collaboration between mental health treatment providers and social workers can significantly help to bridge the gender gap in mental health service delivery, access to treatment, empowerment of patients and families and reduce disability, stigma and discrimination.

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Chapter 9

Urban Women and Mental Health Concerns in India Vibhuti Patel

Introduction Women’s movement has provided fresh inputs in terms of individual and group counselling, popularly known as ‘consciousness raising’ exercise, a form of mutual counselling that enables women as a group to share experiences, problems, feelings, dreams, utopia and action plan for rebuilding shattered lives. This process of attaining feminist consciousness allows women to recognize that what they perceive as personal problems is shared with others in a non-threatening and non-power-oriented atmosphere. It also enables women to realize what they think of as resulting of living in patriarchal society. ‘Consciousness raising can be seen as enabling women to overcome false consciousness’ (Kramarae and Dale 2000). It empowers women to come to a realization of their own potential and makes them autonomous, self-dependent in their decision-making power and emotionally self-reliant. It is an ongoing process that brings about personal and collaborative change as opposed to structural change. The need for small groups/informal group discussion is emphasized in this method.

Manifestations of Depression Depression in women manifests in headaches, sleepless nights, constant tension, detachment, irritability, loss of appetite, dryness of mouth, fear, self-blame, lack of concentration and lack of interest in any kind of activity. Although chronic headaches may not be psychosomatic, they can be caused by depression or anxiety. “Although chronic headaches may not be psychosomatic, they can be caused by depression or anxiety. Thus, counselling can help you identify and address emotional concerns and V. Patel (B) School of Development Studies, Advanced Centre for Women’s Studies, Tata Institute of Social Sciences (TISS), Mumbai, India e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2020 M. Anand (ed.), Gender and Mental Health, https://doi.org/10.1007/978-981-15-5393-6_9

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should be considered as part of your treatment” (Goel 2000). There are two types of stressors leading to mental disorder. Biochemical stressors are hormonal fluctuations at the onset of puberty, premenstrual phase, post-partum phase and menopause. According to Dr. K Ravishankar, “Oestrogens influence brain chemicals like serotonin and nor epinephrine that are involved in headaches. An imbalance in serotonin levels has, in fact, been implicated in disorders like migraine and depression” (Times of India, 21-3-2002). Psychosocial stressors originate from the external social environment such as women’s inferior social position, lack of power, homelessness, economic hardships, and man-made or natural disasters. They create learned helplessness (women’s seeming passivity during crisis such as domestic violence, accidents) and reduce motivation to lead an active life. Stress-related mental health issues are illness in the family, death of one’s spouse, divorce, accident that might reduce or destroy women’s ability to shoulder responsibility. After marriage, women get displaced which brings about cultural loss and bereavement, loss of social networks and supports, loss of traditional healing sites. Psychological stages through which women pass are—enduring, suffering, reckoning, reconciling and normalizing. The successful completion of therapeutic cycle depends on how conducive the physical and emotional systems are. Sometimes, hysteria can also open more opportunities and increased freedom/space with added costs. Women cope with tension by crying, talking it over, praying and engaging in creative work–music, art–craft–reading–studies–community work, team building.

Approaches to Mental Illnesses Universalist ETIC approach uses diagnostic categories of mental illnesses such as neurosis, schizophrenia, psychosis, mania, phobia, paranoia, so on and so forth. Psychiatric labelling does not take cognisance of material reality faced by women on day-to-day experiential levels. It obscures social reality such as riots, natural disasters, fire and accident while dealing with phobia among women. While working with women victims of riots, we should know that their phobia about men has a basis in the fact that they have witnessed killings and rape. Hence, medicalization of mental health in the Draft National Health Policy 2001-III has been criticized by women studies (Davar 2002). EMIC approach emphasizes cross-cultural psychiatry and evaluates phenomena of mental illness from within a culture. Traditional treatment of the mental illness is used to be meditation, yoga, group singing and listening to the discourser. A culturally sensitive counselling on mental health consequences of trauma takes into consideration women’s sociocultural environment. ETIC-EMIC debate gave way to new cross-cultural psychiatry where the emphasis lays on the different contexts of mental illnesses in different cultures, not on biomedical categories. Now, there are no two opinions about the statement that psychotherapy

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should keep into consideration multicultural aspects of women’s existential reality (Amico 1978). Psychiatrists use chemotherapy, i.e. administration of antidepressants and sedatives, shock therapy which induces shock, with or without convulsions, in a patient by means of insulin or electric current through brain. Individual psychotherapy includes hypnosis, suggestions, supportive therapy, re-education, desensitization and other forms of consultation, group psychotherapy, family therapy and psychoanalysis (Shertzer and Shelley 1968). Four phases of healing cycles (Kearney 1999) are: 1. Enduring—anxiety, grieving and loss of past. 2. Acceptance—reality testing, preparedness and reckoning of the future reconciling, evaluation of self and resources, recuperating. 3. Recovery—rebuilding life, maximizing options, setting new goals, healing. 4. Normalizing—stability and routines, building relationships and community. Unequal relationship between professional counsellor, who is UP THERE, and the seeker, who is DOWN BELOW creates a communication gap. In case of women, this inequality is compounded by subjugation of women by the patriarchally structured psychiatric system. Focus on ‘feminine qualities’ pathologizes all physiological changes of a woman, in childhood, adolescence, reproductive age and menopause. Philosophical basis of psychiatry as a biomedical discipline prevents the mental health professionals to take into consideration larger reality and macro-issues resulting from socio-economic and political factors. Psychiatry focuses on treating the individual symptom while ignoring the disease. ‘Diagnosis’ frequently arouses protests of indignation about labelling people as ill and treating them as impersonal objects (Noonan 1983). Limitations of biomedical perspectives lie in their narrow focus on somatic and psychological factors in their diagnostic efforts, ignoring the impact of sociocultural and socio-demographic factors. In India, the focus is more on the treatment of the illness, not on preventive and promotive efforts. Marginalization of mental health concerns results from the understanding that mental distress is a manifestation of an individual problem, not directly related to social oppression and not common to all women (Vindhya et al. 2001).

Worsening Socio-Economic and Political Situation and Mental Health of Women Experiences from both industrialized and developing countries have revealed that the prevalence of common mental disorders or minor psychiatric morbidity is high among the urban low income and marginalized population. Women among them are even more vulnerable. Globalization, structural adjustment programmes, increasing conflict with neighbouring countries and ongoing sectarian violence on caste, ethnicity and communal lines within the country (Medico Friends Circle 2002) have put the population of our country at high risk of mental illnesses (Ali and Jaswal

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2002). Alert India is a large NGO with 550 community workers working among the marginalized sections of Mumbai metropolis. Their women health workers found that women who must deal with financial hardship experience tremendous stress. Moreover, women within community are affected differentially depending on their own place in the Indian socio-economic hierarchy. In this regard, female-headed households are most vulnerable to mental distress. The mental health professionals are only geared for the episodic disasters and not the enduring disasters. Hence, there is a need for interdisciplinary mental health interventions. Professional counsellors act as facilitators in self-help groups (SHGs). They use the technique of mutual counselling to identify areas of strategic interventions.

Need for Culture-Specific Approach in Counselling Respect for basic human rights demands that the counsellor addresses the issues concerning cultural mindsets and behavioural variety that determine women’s mental responses to tragedies. If this variety is not appreciated, counselling will end up being reductionist and homogenizing. Here, the soft wear is not formal education, but life. Mental health of women victims and survivors of tragedy demands multifaceted approach. Individual counselling by the professional counsellor can be helpful in breaking ice. At the same time, women with similar experiences can empower each other by narrating their problem areas and finding solutions.

Patriarchal Biases of the Mental Health Establishments The mainstream mental health professionals are unable to impart the required counselling to women due to misogyny. Stereotypical understanding about women’s role in the family and society governs their psyche, and if the so-called mentally ill woman does not fit in that mould, she is declared ‘socially incompetent’ woman. Witch hunting of lesbians by the mainstream psychiatrist is so strong that even All India Institute of Medical Sciences has a special package for counselling, ‘to correct deviant behaviour’ of the lesbians. Subordination–domination relations between men and women are re-emphasized in the mainstream counselling.

Sexual Violence and Mental Health Sexual assault, molestation, rape, sexual harassment at workplace, child sexual abuse and nuisance calls cause psychological disturbances among girls and women. The trauma of sexual violence sparks off tension and anxiety at a dangerous level. Their mental health problems are manifested in anxiety, fear, avoidance, guilt, loss of

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efficiency, lack of coordination, depression, sexual dysfunction, substance abuse, relieving the traumatic incidents through memory, suicidal attempts, eating disorders, disturbed sleep patterns, fear of encountering such situation once again. It is found that ‘women who undergo extreme sexual violence experience a loss of self and selfesteem following the shock inflicted on them. When there is a continuous period of traumatic stress, it becomes chronic, lessening the individual’s ability to do any kind of constructive work’ (Nair and Nair 2002). Hence, this form of male violence towards women is an important issue that demands public attention. Women’s organizations have taken up this issue at a local, national and global level.

Domestic Violence and Mental Health of Women Discourse on mental health of women in the family situation gained serious consideration in the context of campaign against violence against women. In domestic violence situations, predicament of women is determined by their position in power relations vis-à-vis the rest of the family members. Many social work researches which attribute deviant behavior of adolescent girls to their working mothers, guilt trip women by narrowly focusing on single parameter (Mallon and Hess 2005) and ignore factors such as peer-pressure, media, overall standards of morality in our society and power relations in the nuclear/joint family. Such researches are used by some counsellors to cage women into domesticity and divert the attention from generation of genuine support system for developmental needs of the daughters of working mothers. Women’s rights organizations which are doing support work for women in distress have started giving due importance to counselling (Tellis 2002; MASUM 2001).

Adolescent Girls and Counselling The most mind-boggling problems faced by adolescent girls are decision-making in the day-to-day life, self-dependence and career. Rapid changes in the socio-economic and cultural reality, parental expectations, values and norms, rising levels of competition and pressure during examination time and a breakdown of traditional family structures are factors that accelerate this alarming trend (Kumar 1994). Examinationrelated anxiety results into sharp rise in girls hurting themselves deliberately, leaving homes or killing themselves. Fear of failure is a root cause of all qualms. A large number of students and their parents are seeking professional help. Consulting a psychiatrist is no longer a taboo as the psychiatrist responds to cries for help from a crippling academic burden. According to them, we have more problem parents than problem children. Providing good and healthy role models is very important. Parents who want their children to develop high self-esteem should make a point of treating them with respect and dignity. Concept of fiscal hygiene is important for

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girls to understand the value of clean money earned through hard work. Today’s adolescent girls are at the crossroads. But every crossroad leads to new roads. Information revolution has made adolescent girls more aware and precocious. They must enhance their knowledge base. Broadening one’s personal horizons is a sure way of tackling the crisis within oneself. Today’s girls find the values instilled in them since their childhood hollow in real life. Romance is found utilitarian and consumerist. The economic security is bleak, and emotional security is becoming a victim of uncertain times. Globalization has led to the emergence of apparently homogeneous lifestyles, and necessities and comforts through media images, whereas the reality of life is pathetically at variance with resources required to maintain such a life. This has further deepened the crisis of the youth. Dictatorial atmosphere in the family, educational institutions and the community life makes adolescents feel left out of the decision-making processes affecting their lives. Hence, it is very important to understand that “Inclusion is trend, Such as democracy, Freedom and justice for all. All means all, No buts about it. Inclusion is opposite of exclusion. Inclusion is no to boycott. Inclusion is a battle cry. Challenge to the parents, Child’s cry for his/her existence… For welcome, for embrace, To be remembered fondly…for award For gift of love…like surprise, Like treasure. Inclusion means clean game, General knowledge, courtesy, hard work. Inclusion is great in its simplicity, And surprising in its complexity. Instead of investing in jails, mental asylums, hospitals, refugee camps, To canalise resources for creating true homes, True life, true human beings… For humanising life.” Marsha Forest. Both in the private and in the public spheres, we need to give more space for development to the adolescent girls.

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Counselling for Substance Abusers Support resources for substance abusers are counsellor, family members, significant peers and school or treatment staff. Group therapy is an effective intervention method with abusers. It facilitates the process of recovery of addicts (Gonet 1994). Sharing of experiences by the abusers shows them ways to empower each other. Self-help groups of abusers are more effective as they avoid problems generated due to different wavelengths.

Counselling for HIV/AIDS Patients This is a very important issue faced in the twenty-first century. Counselling for dealing with social stigma and creating an alternate support network are the most important aspects of providing emotional support to the HIV/AIDS patients. The Lawyers Collective HIV/AIDS Unit holds monthly drop-in meetings, with an objective of sharing information and experiences, and resolves mind-boggling issues affecting the lives of HIV/AIDS patients. It also provides legal aid and allied services to the needy. ‘The main objective of the unit is to protect and promote the fundamental rights of persons living with HIV/AIDS who have been denied their rights in areas such as health care, employment, terminal dues like gratuity, pension, marital rights relating to maintenance, custody of children and housing’ (Positive Dialogue 2000).

Electronic Media and Mental Health People are inside the TV because there is a vacuum outside the TV. Different standards of morality for men and women are created by the film, television serials and advertisement industry. Boys and men who watch pornography are always on the lookout for innocent adolescent girls. These girls are the victims of pornography, blackmail and physical/psychological coercion. Adolescent girls working as domestic workers do not have any emotional support, as there are hardly any television and radio programmes for non-student urban youth. Dehumanization of women can be prevented by promotion of women’s agency in the media so that women can lead intellectually, psychologically and emotionally self-sufficient life.

Counselling in the Shelter Homes for Women The most promising solution to confusion and disorientation among the women inmates of shelter homes is a democratic space for brainstorming as autism is one of

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the main problems faced by them. Informal set-up is more congenial to their personal and career counselling. Workers at the shelter homes for women and girls need to be made to understand that behind every behaviour, there is a story. It is important for them to know the story. Panel of psychotherapists and psychoanalysts in the shelter homes should also conduct the staff development programme so that the staff can handle post-trauma stress disorder among the inmates with empathy rather than resorting to victim blaming.

Mental Health and Reproductive Rights of Women Societal attitude towards Indian women as son-producing machines creates painful mental problems for women. Woman’s body is de-linked from her subjectivity. Premenstrual syndrome (PMS) and post-partum depression (PPD) are regarded as general complaints concerning women’s reproductive abilities. Weapon of premenstrual syndrome as a debilitating factor has been used to run down women in the family and at the workplace. PMS is a political category, which conveys that biology is destiny for women. Instead of focusing on the genuine issues concerning premenstrual discomfort in terms of fatigue, headache, cramps, headaches resulting into depression and crying spells, PMS provides reductionist and reactionary explanation for women’s discontent. Women do not have right to decide how many children should they have and at what interval. New reproductive technologies have robbed women of their individuality and reduced them into spare parts for either scientific experimentation and/or sale. NRT values women only for their ovaries, uterus, foetus, that too preferably male. NRTs have caused tremendous psychological burden on women in the arena of sexual activity for procreation or only for recreation without procreation with the help of contraception or abortion. Researches over last 3 decades have highlighted mental problems associated with repeated induced abortions, long-acting hormone-based contraceptives or conception-inducing drugs. Instead of using humane healing techniques of music, fragrance therapy, getto-gathers to deal with discomfort during pregnancy and post-partum depression, bio-medical intervention of giving tranquilizers and electro-convulsive therapy are promoted by the psychiatrists. This is the most vulgar example of the medicalization of the natural processes of women’s bodies. Gender-sensitive training programmes should be organized for medical officers of primary health centres and women health workers adopting perspective promoted by the UNFPA (2002).

Menopause and Mental Health of Women Many psychologists have attributed harassment of daughter-in-law by her mother-inlaw to menopause. But it is not true for all women. Many women find it a liberating experience to stay with their in-laws. It all depends on how society and family treat

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an ageing woman. Pathologization of menopause and negative attributes given to ‘old hag’ (sadeli buddhi) experienced by women are responsible for identity crisis and depression among women during this period. Here, the role of counsellor is to recommend activities for self-actualization and a healthy diet and vitamin supplements to menopausal woman. Exercise is very important to increase conversion of androgens to estrogens.

Women and Epilepsy Disability and impaired quality of life caused by epilepsy can be reduced by ‘psychiatric and psychosocial referral counselling on how to live with refractory seizures and advise on vocational rehabilitation’ (Shah 2002). Persecution and discrimination against epileptic women should be prevented by giving scientifically accurate public education through mass media. For the curriculum of community workers training programme, module on epilepsy, seizure, convulsions should be incorporated.

Mental Health of Women Senior Citizens The most talked-about problem concerning mental health of elderly women is dementia, i.e. ‘loss of cognitive functioning, memory, language abilities, abstract thinking and planning’ (Garner and Mercer 2000). Dementia is often reversible. Irreversible dementia can arise due to amnesia, Huntington disease and Alzheimer’s disease (AD). Modern medicine treats this problem with oestrogen replacement therapy, non-steroidal anti-inflammatory drugs and vitamins. Feminist senior citizens deal with mental problems of elderly women by providing spiritually rich and emotionally and intellectually stimulating group life to them. Discourses, singing, outing, social service, meditation and mutuality and reciprocity in human relations make great contribution towards their mental health. Vardhana, a group of feminists, has defined women above 60 years of age as ‘Women of Age’ and has provided a democratic and development-oriented platform to Women of Age (Vardhana 1999).

Mental Health of Women in the Mental Hospital Pathologization of women by using diagnostic labels is a major cause of stigmatization and ostracism for women. Women’s groups are demanding that pigeon-holing of people into set slots must stop. Interaction with the mental health professionals is used by the family members and the community to declare the concerned woman ‘unfit’ to live in the family, be a parent, function as an autonomous individual or take up a job. Husband’s family uses the episode to dispose her of or debar her from

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property right or right to live in a matrimonial or parental home. ‘Madness certificate’ of the mental health professionals is used by husbands to divorce, desert or throw out wives from their matrimonial homes. Women are admitted in the mental asylum as per the directives of the Mental Health Act, 1987, and Lunacy Act, 1912. Once dumped in a mental asylum, it is impossible for her to get out of it even after complete recovery. ‘Women in the mental hospitals have fewer visitors, are abandoned or tend to stay on longer than men within the institution. There are fewer voluntary patients among women than among men. Even in adjudication for a woman’s institutionalization, the official discourses are often coloured by the sex role stereotypes that the judges, police officials and the staff in mental hospitals uphold’ (Davar 2001). Remarks of a social worker after the visit to the mental hospital are apt, ‘The interaction with female patients made me sadder. Almost all of them were abandoned/dumped by families or the police and court got them admitted after they hit the rock bottom. Most of them were forced to face violent situations in their lives and had painful and atrocious account to tell. In many cases, one could see (although without an in-depth study, one cannot claim and prove) that the mental distress, ill health had its roots not in a person’s biology or psychology, but in society, in our social environment’ (Joshi 2004). Iron wall of secrecy about the administration of drugs, surgery and ECT and their side effects needs to be condemned by citizen’s initiatives and ethical medical practitioners. The long-lasting side effects of biomedical approach need to be highlighted. Our mental hospitals need to focus on psychotherapy and counselling which involve therapies that produce positive results and no negative side effects.

Psychological Problems of Women in the Police Custody and Prison Activists working on prison reforms have demanded humane code of conduct for governance of police custody and prisons, so that the inmates are not afflicted with permanent psychological scars. Solitary confinement of women prisoners takes away verbal articulation from them. Interpersonal violence among prison inmates can be reduced by counselling, group discussions and creative expressions. Women political prisoners should not be forced to stay with hard-core criminals in the custody or jail.

Role of Support and Self-help Groups (SHGs) SHGs provide democratic space for rebuilding broken lives. Non-power-oriented special interest groups provide stimulus for canalization of creative energy. Mutual counselling focusing on experience sharing without preaching or giving sermons can

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help psychologically distressed women reorganize their life and enhance their potential. Speak-out centres can provide platform for community mental health intervention. Here comes the endorsement from an expert, ‘At the height of feminist activism in the 1970s and 1980s, there was excitement in the air as women shared experiences about themselves, their families, their lives and encounters. The growth of women’s confidence and self-esteem knew no bounds as they challenged established theories about law, work, justice, equality and medicine. They talked late into the night, wrote pamphlets, stuck wall posters, spoke at public meetings, filed writ petitions. They felt reassured that theirs was not an isolated or individual problem. The group’s endorsement and sharing of painful experiences perhaps did much more for mental health than all medicines in the expert’s books. The women’s movement helped avert many breakdowns’ (Shatrughna 1999). Enduring therapeutic engagement at community level can be group singing, festival celebrations, discourses on women’s issues and public meetings. Developmental Input: Cosmetic counselling offered by agony aunts is of no use. Breakthrough counselling is need of an hour. To make women’s material reality more secure, liberating and healthy is the only alternative to get out of repeated attacks of mental illnesses. Developmental counselling aims at removal of chronic conflict situation in women’s lives that is associated with high mental health morbidity. It is more than a remedial service. It believes that “involvement, readiness and commitment on the part of the counsellor are necessary and basic conditions for counselling success” (Don and Caldwell 1970). It is concerned with the development and facilitation of human effectiveness. It increases self-direction and evolves better problem-solving and decision-making abilities. This is the central axis around which feminist therapy or counselling revolves. It emerged in the wake of the women’s movement as an alternative to hegemonic patriarchal mental health establishments which depended on biomedical approach to deal with the innate feeling of unhappiness in women. It is sad that in recent times, the counselors have become astrologers. Counselor should be proud with the arrogant and humble with the courteous. He/she should do only supportive counseling. At times, he/she needs to provoke. Role-playing is an excellent procedure for learning about counseling. Budgetary allocation for medical aid to treat mental illnesses of women should be enhanced. Mentally ill women need legal protection in terms of property rights and right to dwelling place. We need to create protective environment in personal and public life to prevent mental illnesses among women, e.g. efforts to prevent man-made disasters such as riots, loot and rampage. Mental illnesses result into deskilling of the individuals concerned. Hence, there is a need to evolve a plan of action for the reskilling based on their preferences and abilities. Halfway homes should be created where the mentally ill women can do productive work during the day and go home in the evening. After the recovery from the mental illnesses, they should be employed (Patel 2002). Financial security helps in rebuilding their sense of self-esteem. The most successful healer is one who avoids victim blaming and provides patient listening (Nelson-Jones 1994). After talking/catharsis, the seeker feels better. Girls and women with communication disability need special help (Jyoti, 2002). At the same time, ‘Reversing the process of alienation by consciously building community networks is a must. Mental health

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professionals should be seen in the community rather than in the secure institute or clinics’ avers a well-known psychiatrist, Dr. Harish Shetty (2001).

Training Programmes on Counselling Sensitization and training of general practitioners and other health personnel to mental health, particularly, minor psychiatric morbidity (anxiety–depression) are a must. There is a need for social counsellors at health posts and public hospitals who are in touch with NGOs providing institutional support to women in social distress. Sensitization of teachers, community workers, youth groups and women’s organizations is extremely important. Training sessions for professional and paraprofessional volunteers should focus on supportive networks, group cohesion and solidarity. Training should include modules on interviewing skills, history taking, mental status examination. Electronic and print media should be trained in sensitizing the general public about psychological response to violence and providing information about referral services as women and children affected by domestic violence, man-made or social disasters have special psychological needs. Counselling ought to make women more aware about their problems and the oppression they face. Therapy can provide alternatives to deal with their problems. Counselling can be used to bring to the fore the cognitive facility required to recognize danger and threat to life, to assess the options and to leave if necessary, among women victims of violence. Counsellors have become astrologers. Counsellor should be proud with the arrogant and humble with the courteous. Do not do only supportive counselling. At times, you need to provoke. Role-playing is an excellent procedure for learning about counselling. Role-playing situations can be easily developed from the experience of people (Ligon and Mc Daniel 1970). The ethics of valuing and respecting others must be observed by the counsellor (Seden 1999). Common characteristics required from the counsellor are concern, emotional investment, cognitive detachment, sensitivity and introspection (Perez 1998). The counsellor should know that healing is a part of empowerment.

Conclusion Civil society and the state should provide more and more opportunities to women of all age groups for self-actualization so that women can achieve high level of mental health. Respect for diversity, plurality and multicultural outlook ensure democratic and tolerant milieu that is conducive for mental health of women. As compared to institutionalization based mainly on biomedical intervention, community or familybased rehabilitation of mentally ill women based on human touch is far more effective.

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References Ali, N., & Jaswal, S. (2002). Political unrest and mental health in Srinagar. The Indian Journal of Social Work, Special Issue—Mental Health Consequences of Disasters, 61(4), 598–618. Amico, E. (1998). Reader’s guide to women’s studies. New York: Fitzroy Dearborn Publishers. Davar, B. (2001). Women-centred mental health: Issues and concerns. Vikalpa-Alternatives, Special Issue, Gender and Transformation, IX(1 & 2), 117–130. Davar, B. (2002). Draft National Health Policy 2001-III, mental health: Serious misconceptions. Economic and Political Weekly, XXXVII (1), 20–22. Don, D, & Caldwell, E. (1970). Developmental counselling and guidance—A comprehensive school approach (p. 87). Cambridge, MA, USA: Harvard University. Garner, D., & Mercer, S. (Eds.). (2000). Women as they age (p. 91). New York, NY: The Haworth Press. Goel, D. (2000). History of headache. Health Action, Special Number-Managing Neurological Disorders, 15(6), 13–17. Gonet, M. M. (1994). Counselling the adolescent substance abuser—School based intervention and prevention (p.160). New Delhi: Sage Publications. Joshi, L. (2004). At the fag end…a visit to Yervada Mental Hospital. Aaina—A Mental Health Advocacy Newsletter, 2(1), 7–8. Jyoti, A. (2002). Improving approaches to people with communication disabilities. Disability Dialogue, III, 1–12. Kearney, M. H. (1999). Understanding women’s recovery from illness and trauma. New Delhi: Sage Publications. Kramarae, C., & Dale S. (Eds.). (2000). Routledge international encyclopaedia of women—Global women’s issue and knowledge (Vol. I, p. 221). USA: Routledge. Kumar, L. (1994). Adult and adolescence—Lives of compromise. Generation Next—The Complete Youth Magazine, 2(2 &3), 23–24. Ligon, M. G., & Mc Daniel, S. W. (1970). The teachers’ role in counselling (p. 82). Upper Saddle River, NJ: Prentice-Hall, INC. MASUM. (2001). Mahila Sarvangeen. Utkarsh Mandal, Pune: Annual Report. Mallon, G. P. P., Hess, M. (2005). Child welfare for the Twenty-first Century: A Handbook of Practices, Policies, and Programs. USA: Columbia University Press. Medico Friend Circle. (2002, May 13). Carnage in Gujarat—A public health crisis. Mumbai: MFC. Nair, J. R., & Nair, H. (2002). (En) gendering health: A brief history of women’s involvement in health issues. Samyukta—A Journal of Women’s Studies, II(1), 44. Nelson-Jones, R. (1994). Practical counselling and helping skills (p. 12). Mumbai: Better Yourself Books. Noonan, E. (1983). Counselling young people (p. 48). New York, NY: Methuen. Patel, V. (2002). Women and health—An Indian scenario. Perspectives in social work (Vol. XVII, Issue No. (1), pp. 22–29). Mumbai: College of Social Work, Nirmala Niketan, College of Social Work. Perez, J. (1998). The initial counselling contact. Guidance Monograph Series II Counselling (p. 28). Boston: Houghton Miffin Company. Philip, T. (2002). Impact of employment of mothers on mental health of adolescent children. Perspectives in social work (Vol. XVII, Issue No. 1, pp. 30–38). Mumbai: College of Social Work, Nirmala Niketan, College of Social Work. Positive Dialogue. (2000, August). Lawyers collective HIV/AIDS Unit, Mumbai. Newsletter, 6, 4. Seden, J. (1999). Counselling skills in social work practice (p. 142). Philadelphia: Open University Press. Shah, P. (2002). Psychological aspects of epilepsy. Journal of Indian Medical Association, 100(5), 295–298. Shatrughna, V. (1999). Forward. In B. Davar (Ed.), Mental health of Indian women. New Delhi: Sage Publications.

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Shertzer, B., & Shelley, S. (1968). Fundamentals of counselling (p. 14). Boston: Houghton Miffin Co. Shetty, H. (2001). Prevent suicide. Save Life One India, One People, Special issue on Prescriptions for Healthcare, 4(12), 21–22. Tellis, J. (2002, April). Zero tolerance (pp. 10–11). Mumbai: Humanscape. Times of India, Mumbai Edition, 21-3-2002. UNFPA. (2002). Training modules on gender and reproductive health. India: United Nations Population Funds. Vardhana. (1999). The women of age—Women and ageing in India (p. 1). Vacha: Mumbai. Vindhya, U., Kiranmayi, A., & Vijayalaxmi. V. (2001). Women in psychological distress-evidence from a hospital based study. Economic and Political Weekly, xxxvi (43), 4081–4087.

Chapter 10

Female Criminality, Mental Health & the Law Saumya Uma

Introduction Women’s mental health has received inadequate attention from the law makers, implementers and interpreters in India, more so in the arena of criminal law. The impact of mental health on women is disparate. The stigma associated with mental illness, a dearth of appropriate government-initiated community-based services, lack of awareness among family members and poor financial resources cause obstacles in accessing professional assistance. In the case of women, these factors often cause their institutionalization. Biological and physiological factors as well as social conditions exacerbate the mental health challenges faced by women. The socio-economic disparities between men and women contribute to a gendered nature of access to treatment and professional assistance. Since women are not considered breadwinners, women facing mental health challenges are more likely to be ignored or prevented from seeking professional assistance. Law is an important tool to address such gender inequalities that exist in the field of mental health. The present article discusses gendered aspects of mental health and the law, with a particular focus on female criminality and criminal law’s treatment of women accused of heinous offences. The article undertakes the analysis primarily through a critical examination of judgments delivered by the High Courts and the Supreme Court of India.

S. Uma (B) Associate Professor, Jindal Global Law School, O.P.Jindal Global University, Sonipat, India e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2020 M. Anand (ed.), Gender and Mental Health, https://doi.org/10.1007/978-981-15-5393-6_10

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Contours of Law At the core of international standard of human rights is the right to life with dignity and personal liberty (Article 1, UDHR). Women’s rights are now recognized as human rights. The United Nations Convention on Rights of Persons with Disabilities, adopted by the General Assembly in 2006, lays down eight important principles, which are (Article 3, UNCRPD): 1. Respect for inherent dignity, individual autonomy including the freedom to make one’s own choices, and independence of persons; 2. Non-discrimination; 3. Full and effective participation and inclusion in society; 4. Respect for difference and acceptance of persons with disabilities as part of human diversity and humanity; 5. Equality of opportunity; 6. Accessibility; 7. Equality between men and women; and 8. Respect for the evolving capacities of children with disabilities and respect for the right of children with disabilities to preserve their identities. Mental illness falls within the purview of disability in this Convention. In addition, Article 6, of the Convention recognizes that women and girls with disabilities are subject to multiple discrimination, and places responsibility on state parties to ‘take measures to ensure the full and equal enjoyment by them of all human rights and fundamental freedoms (Article 6(1), UNCRPD)’. The Convention further calls upon states parties to take ‘all appropriate legislative, administrative, social, educational and other measures to protect persons with disabilities, both within and outside the home, from all forms of exploitation, violence and abuse, including their genderbased aspects (Article 16(1), UNCRPD)’. India ratified this Convention in 2007 and is therefore mandated to not only respect, fulfil and promote its provisions but also incorporate and implement them through domestic laws and policies. The Indian Constitution guarantees the right to life with dignity to all persons (Article 21). It also provides for gender equality and non-discrimination on the ground of sex (Article 15(1)). Yet, persons with mental disorders and disabilities face a range of violations of their fundamental rights under the Constitution, including curtailment of their liberty, privacy, bodily integrity, sexual autonomy, freedom of movement and freedom of speech and expression. The combined forces of patriarchy and prejudicial/discriminatory treatment of society against mentally challenged/impaired persons has placed women in a precarious position. Law, as a powerful tool for governing society and promoting its well-being, is mandated to acknowledge, address and redress the gendered impact of mental health challenges. Yet the laws, through their provisions, lack of/wrongful implementation and judicial interpretations, fail to conform to constitutional guarantees, or violate them in letter and spirit. Further, laws often mirror social attitudes and perpetuate gender stereotypes and discrimination.

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For example, family law is a site of rampant discrimination against mentally challenged women. The Hindu Marriage Act (1955) S. 13(i) (iii) provides that a person can petition the court for divorce or nullity of marriage if his/her spouse is of ‘incurably unsound mind’. A paradox is that effective treatment of many forms of mental disorders is now available through developments in medical and forensic science, and yet, courts continue to grant divorce or annul marriages on the ground of ‘incurable unsoundness of mind’ of a party to the marriage. Researchers analysing family law provisions highlight several provisions that deny persons with mental illnesses the right to marry (Choudhary and Shikha 2015); in the case of women, past history of mental illness drastically reduces their chances of marriage, thereby forcing their families to conceal the fact. A suppression of this fact leads to a risk of the marriage being annulled or terminated (Choudhary and Shikha 2015). Not surprisingly, a paper that analysed judicial proceedings in family law cases in Pune found that more husbands use the ground of mental illness in seeking divorce or nullity as compared to wives (Pathare et al. 2015). Various other laws deal with and infringe upon the rights of persons with mental disabilities. In fact, the term ‘unsoundness of mind’ is used in at least 150 Indian statutes, and yet, it is not defined (Pathare 2017). Such persons cannot enter into contracts or enjoy property rights. In recent years, the Rights of Persons with Disabilities Act (RPDA) 2016 and the Mental Healthcare Act (MHA) 2017, which have attempted to adopt and implement international standards, have been the focus of public discourse and discussion. Experts have opined that the MHA 2017 is liberal in principle but disappointing in its provisions, as it attempts to shrink state responsibility and shift the burden to families (Kumar 2018). Given that the family is a major site of discrimination, exploitation and violence against women, the gendered impact of the law is an issue that warrants examination. It has been further opined that though the MHA 2017 has conformed to the principles set out by the UNCRPD, when it comes to the rights of women with mental illness and bringing them at par with the other sections of the society, the terrain is rocky and is full of obstacles, and that the law requires an effective implementation vis-à-vis women (Kaur 2018). The need for gender-sensitive disability laws has been emphasized time and again (Raha 2009).

Crimes, Mental Health of Women and the Law Feminists have critiqued how laws tend to be formulated based on male experiences and patriarchal perspectives, with a distinct protectionist and paternalistic approach that reinforces patriarchal values (Barnett 1998; Scales 2006; Smith 2010). Substantive criminal law in India is gender neutral to a large extent, with a distinct exception being offences against women. These are specifically defined in the Indian Penal Code and punishment prescribed for the same. Yet, even in provisions on offences against women, a patriarchal perspective is evident. The narrow definition of rape that focused solely on peno-vaginal penetration (far removed from women’s lived

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realities) was applied in India for a century and a half, and after decades of advocacy by the women’s movements, it was amended in 2013 (Mehra 2013). The Indian criminal law provision on adultery, which carried the underlying presumption of husband’s exclusive ownership over the wife’s body, was declared unconstitutional in 2018 (Joseph Shine vs. Union of India 2018). These are examples of the male-centric formulation of criminal law that all women are subjected to. Scholars have critiqued the inherent bias against women prevalent in Indian criminal law (Kumari, 1999; Ramanathan 1999). Women with disabilities—as victims of crimes—are given a horrific treatment by the legal system, with women’s movements, feminist lawyers, academics and activists making a concerted effort to engender the law and legal processes. In the criminal law amendments to rape, which were effected in 2013, provisions were included—in substantive, procedural and evidentiary law—to address offences committed against women with physical and mental disabilities (Jiloha 2013). A report (Human Rights Watch 2018) found that despite the criminal law reforms on sexual violence, these were not effectively implemented with regard to women and girls facing physical and mental disabilities. It further found that such women faced challenges in access to justice, throughout the criminal justice process—in reporting crimes to the police, in receiving timely and appropriate medical assistance, in having complaints investigated in an efficient manner, in navigating the court processes and in being granted adequate compensation (Human Rights Watch 2018). In comparison to an examination of the response of criminal law vis-à-vis women victims with mental health challenges, there has been lesser attention paid, and consequently lesser discourse, on the application of criminal law to such women charged with commission of heinous offences. Where women facing mental health challenges commit heinous offences such as murder and grievous hurt, does the mental health status have a bearing on their criminal responsibility under law? Under what circumstances are women exonerated, and under what circumstances do they face diminished criminal responsibility due to their state of mental health? The present paper explores some such aspects of female criminality, mental health of women and the law.

Unsoundness of Mind as a General Defence It is a cardinal principle of criminal law that the culpability or criminal responsibility of a person is dependent both on actus reus (the criminal prohibited act) and mens rea (the intention to commit a crime). Indian criminal law includes general defences/exceptions that would allow the accused to escape liability for the offence committed, as well as specific defences for certain offences that act as mitigating factors for diminished criminal responsibility. Criminal intent is of utmost importance in pinning criminal responsibility on an individual for a commission of an

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offence. Conversely, a person of an unsound mind who commits an offence, without an understanding that the said act is unlawful, cannot be imputed with criminal responsibility. ‘Unsoundness of mind’, also referred to as ‘legal insanity’ is an important defence under criminal law. M’Naghten rules of 1843—laid down by the House of Lords in England in the case of R vs. M’Naghten (1843), form the backbone of the defence of unsoundness of mind/insanity in English law (1843) and consequently, was incorporated in the Indian Penal Code in 1860. Section 84 of the Indian Penal Code states as follows: Nothing is an offence which is done by a person who, at the time of doing it, by reason of unsoundness of mind, is incapable of knowing the nature of the act, or that he is doing what is either wrong or contrary to law.

It is pertinent to note that the term ‘unsoundness of mind’ is not defined in the statute. The M’Naghten rules have led to a distinction between ‘medical insanity’ and ‘legal insanity’; the former consists of various types of mental illness/impairment/disability that are medically recognized; however, only a small portion of them, which adversely impact or impair the cognitive faculties, and do so to such an extent that the accused person is incapable of knowing the nature of his/her act or that the act is wrong or contrary to law, constitute legal insanity. On the other hand, somnambulism and epilepsy which do not medically classify as ‘insanity’ are legally deemed ‘insane’ because they are acts performed involuntarily in an unconscious state of mind (Raveesh et al. 2013).

Premenstrual Stress Syndrome and Legal Insanity Premenstrual Stress Syndrome (PMS) experienced by women and its relation to criminal responsibility has been an area of consideration in jurisprudence across the world. PMS consists of physical and psychological changes that occur to women for some days prior to the commencement of the menstruation cycle. In 1980–81, PMS was used as a ground for diminishing the criminal responsibility of two women accused of murder (Boorse 1987). Sandie Craddock, who worked as a bartender in London, stabbed a colleague thrice in the chest, in a fit of anger (Regina vs. Craddock 1981). Around the same time, Christine English murdered her partner with a pole in her car, after a quarrel with him (Regina vs. English 1981). Both women defended themselves on the ground of PMS and argued that they ought to be accorded diminished criminal responsibility. The respective courts accepted the defence plea, and convicted them of a lesser offence—manslaughter. A year after her conviction, Craddock was re-arrested for an attempt to murder a police officer; she again pleaded PMS as a defence. Her sentence was mitigated and she was released on probation. There have been cases in Canada, the United Kingdom and the United States, where PMS was used in pre-trial hearings to reduce the charges framed against the accused, or to reduce the sentence awarded to the concerned

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woman (Easteal 1991). Several studies have linked PMS with suicide, violence and aggression, although the methodologies and results have been challenged (Easteal 1991). In the cases where the concerned women succeeded in using PMS in their defence, they were able to prove that (a) The accused woman suffered from PMS at the time of commission of the crime; and (b) Due to PMS, the criminal act in question was involuntary or there was no possession of the requisite mental state (as required by law) for the prosecution. The jurisprudence in India is at a nascent stage on this issue. A distinctive 2018 judgment of the Rajasthan High Court allowed the plea of unsoundness of mind for a woman accused of murder, on the ground that she was undergoing PMS. In Kumari Chandra vs. State of Rajasthan (2018), the accused woman—Kumari Chandra—had pretended to take the children to a temple, thereafter showed them a well, and pushed them into it. Two children sustained minor injuries but were saved, but the third child drowned. The trial court convicted her of murdering one child, attempting to murder the other two and punished her with life imprisonment. The woman, through her counsel, made a plea of unsoundness of mind. Her defence was that at the time of the incident, she was suffering from PMS, and that for a few days prior to her menstruation each month, she tended to become aggressive. She argued that for this reason, if at all she was found to have committed the alleged offences, she should be exonerated. The trial court rejected this defence. On appeal, the High Court had to determine if the woman, at the time of the incident, was suffering from an unsoundness of mind. The High Court accepted the defence of insanity, and observed that the trial court had erred in ignoring the evidence produced by the woman, which, according to the High Court, proved conclusively that she suffered from unsoundness of mind. The High Court stated that due to her mental state, she was incapable of knowing the nature of the act, or that what she was doing was wrong or contrary to law, and hence, she should be accorded the benefit of S. 84 IPC. The High Court’s finding was arrived at based on reliance on the following: (a) Testimony of three medical professionals, who opined that some women become irritable, aggressive, suicidal or violent during the premenstrual stage.1 One of them stated that PMS was evident in 60% of women in the menstrual age, and that among them, 40% faced mild symptoms while the remaining faced moderate to severe symptoms. Two of them had treated the accused woman in the past.

1 These

were Dr. Mahesh Chandra Agarwal—who had treated the woman for ‘psycho-neurotic disorder’, Dr. Gopal Kabra and Dr. G. B. Advani—Head of the Department of Psychiatry of S.P. Medical College, Bikaner, who had treated the accused woman, and had given her tranquilizer as she was aggressive.

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(b) Statements of witnesses in court in support of the fact that the accused woman had PMS and would become violent to the persons around her during those days. The witnesses included her neighbour, sister, sister-in-law and teacher; and (c) Certain published articles (Dalton 1961; Press 1983; Easteal 1991; Singh et al. 2004; ‘Exploring Premenstrual Syndrome in Criminal Law’ 2016) on the issue. The Rajasthan High Court concluded as follows: Although the law has not much developed in India as to the Premenstrual Stress Syndrome being set up as the defence of insanity, yet the accused has a right to plead and probabilise such defence to show that she was suffering from ‘premenstrual stress syndrome’ when the crime was committed and because of her such condition, the offence that she committed was an involuntary act on her part, inasmuch owing to this fact, she was labouring under the defect of reason or was suffering from psychological disorder or unsoundness of mind. She can, within the scope of Section 84 of the Indian Penal Code, set up such a plea and substantiate the same by evidence. In the present case, not one but three doctors, who treated her on different occasions, have deposed in favour of such plea of insanity set up by the defence.

There are some issues of concern with regard to the judgment delivered by the High Court. Firstly, there was no conclusive proof that the woman suffered from PMS at the time of commission of the crime, except for her own statement that her menstruation commenced two days after the crime, when she was in detention. There is no corroborative evidence to prove her claim; the High Court did not find it pertinent to ask for such evidence. Secondly, most of the articles referred to are from 1980s, when medical science has developed vastly in the last few decades. The only recent article referred to in the judgment—a 2015 article from a website called ‘UK Essays’—bears no name of the author and carries a disclaimer that it is written by a student. A dearth of reference to recent scholarly articles from credible sources makes the judicial reasoning hollow. Thirdly, one of the studies (by Dr. Harinder Singh) that the High Court relied upon was based on empirical study of 96 women only—too small a sample to arrive at generalized findings, with no evidence that any of the women had committed or were accused of committing criminal offences. This study heavily draws upon an earlier study by Katharina Dalton, but Dalton’s study was conducted in 1959! In fact, recent studies indicate that the most severe forms of PMS (associated with aggressive behaviour) is prevalent in less than 4% of the population of women (Nuckols 2013). However, the court makes no reference to such recent studies, nor does it lay down clear and cogent guidelines as to the conditions under which women committing crimes while being subjected to PMS may be construed as legally insane. For these and other reasons, some have termed the judgment as regressive (Prasad 2018). Despite these concerns, undeniably, this judgment raises some interesting issues. Does PMS lead to legal insanity? Is it desirable to use PMS as a basis for a defence of insanity in criminal matters, given the fact that the research linking PMS to the absence of cognitive abilities for commission of a crime is far from being conclusive? Using the M’Naghten principles discussed above, could a woman suffering from PMS be considered as ‘labouring under such a defect of reason, from disease of the mind, as not to know the nature and quality of the act she was doing or, if she did

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know it, that she did not know what she was doing was wrong?’ Legal insanity ought not to be conflated with mental illness. Insanity is a legal concept exculpating (that is, excusing) from criminal responsibility an individual whose mental illness at the time of the alleged criminal act led to a particular test of criminal insanity in that particular jurisdiction (Sadoff 1987). Labelling PMS as a mental illness or disease that some women may be inflicted with, is, in itself, problematic; but to conclude that PMS amounts to legal insanity may be an excessive stretch of the legal definition of insanity discussed in the previous section of this article. This issue needs further research and a careful examination, as on one hand, it may fuel prevalent gender stereotypes of all women during the premenstrual stage as irrational, unpredictable, aggressive, violent, depressive, angry, moody, unpredictable, emotionally volatile, suicidal, insane and prone to criminal activity. On the other hand, denying those women who have committed heinous offences while undergoing PMS of a severe nature, the benefit of the defence may be unfair. For these reasons, the courts ought to proceed with caution and satisfy themselves with regard to both the question of law and of fact, drawn from credible sources that incorporate the latest developments in the fields of criminology, psychology and psychiatry, and apply legally sound analysis.

‘Grave and Sudden Provocation’ and the ‘Battered Woman Syndrome’ Unlike legal insanity, which is a general defence and if proved, can exonerate the accused, ‘grave and sudden provocation’ is a partial defence in criminal law. This means that if proved, the accused is not eligible for acquittal, but the criminal liability will be reduced. The Indian Penal Code consists of two provisions in relation to murder—culpable homicide not amounting to murder (S. 299) and murder (S. 300)— which is an aggravated form of culpable homicide, and therefore a more serious offence. Culpable homicide is equivalent to the offence of ‘manslaughter’ under English law; culpable homicide is broader in ambit and is the genus, while murder is the species. The distinction between the two is based on the nature of mens rea— the definite nature of knowledge that the alleged act would result in death, and the probability of causing death. Grave and sudden provocation is an exception that is carved out under the provision of murder (Exception 1 to S. 300 IPC). So, an act of murder would amount to culpable homicide if it was proved that the murder was committed under a grave and sudden provocation. An instance of grave and sudden provocation that was used successfully as a partial defence was in the famous case of K.M. Nanavati vs. State of Maharashtra (1962), where the accused murdered his wife’s lover. In Nanavati’s case, the court laid down the parameters under which the partial defence of grave and sudden provocation may be applied to a case of murder. It stated as follows:

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(a) The test of “‘grave and sudden’” provocation is whether a reasonable man, belonging to the same class of society as the accused, placed in the situation in which the accused was placed, would be so provoked as to lose his self-control. (b) In India, words and gestures may also, under certain circumstances, cause ‘grave and sudden’ provocation to an accused so as to bring his act within the First Exception to Section 300 of the Indian Penal Code. (c) The mental background, created by the previous act of the victim, may be taken into consideration in ascertaining whether the subsequent act caused ‘grave and sudden’ provocation for committing the offence. (d) The fatal blow should be clearly traced to the influence of passion arising from that provocation and not after the passion had cooled down by lapse of time, or otherwise, giving room and scope for pre-meditation and calculation.

Application of ‘Grave and Sudden Provocation’ to Women in Abusive Relationships In India, the defence of grave and sudden provocation has been applied, in a number of cases, to a husband who killed his wife who had an extra-marital relationship or her lover (Boya Munigadu vs. The Queen ILR 1881; Jan Muhammad vs. Emperor ILR 1929; K. M. Nanavati vs. State of Maharashtra 1962). However, the ground of grave and sudden provocation has also been applied by the judiciary to women who have killed their husbands, and there is evidence produced in court that they were in an abusive marital relationship prior to the commission of the crime. In these cases, in the words of the judiciary, ‘the victim seemingly is the husband and the aggressor is the wife; but, in reality, it is the wife, who is the victim (Manju Lakra vs. State of Assam 2013)’. For example, in Smt. Suljina Dhan vs. State of Assam (2018), the trial court convicted the woman of murder of her husband, and was sentenced to undergo rigorous imprisonment for life. The husband’s body bore injuries of attack with an axe. At the time of death, the couple was alone in their house. On appeal before the Guwahati High Court, the court noted that it could not be unmindful of the testimony of three witnesses (two neighbours and a daughter of the deceased), all of who stated that the deceased husband was a habitual drunkard and had quarrelled with the accused wife since evening (the incident took place at night after dinner). The accused woman too said that her husband had returned home in an inebriated condition that evening, and quarrelled with her, and tried to attack her with a Dao (traditional sword). The court took into consideration the cumulative statements, and concluded that it is quite unusual for a wife to kill her husband by assaulting him with an axe, and in the absence of a motive to the murder, this was a clear case of grave and sudden provocation by the husband, leading to the death of the husband. It considered the accused woman as a victim of circumstances, and reduced her sentence to five years’ imprisonment.

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The Battered Woman Syndrome In England, the law on grave and sudden provocation was overhauled in the famous case of Regina vs. Kiranjeet Ahluwalia (1992). Kiranjeet Ahluwalia was a victim of domestic violence by her alcoholic and sadistic husband. He would severely assault her on a daily basis, including with a belt. Apart from the violence, the court found him to be a drunkard and that he had extra marital relationships. After one such incident, he fell asleep under the influence of alcohol. She poured petrol on her husband when he was asleep and killed him. She was convicted of murder by the trial court. She took the defence of grave and sudden provocation. On appeal, the defence of provocation was not accepted; however, her criminal responsibility was diminished, taking into consideration the fact that she had faced extreme physical violence from her husband for ten years. This judgment recognized and applied the theory of ‘slow burn’ and the ‘Battered Woman Syndrome’ proposed by Lenore Walker, an American psychologist (Walker 2017). Walker proposed that battered women used various coping mechanisms to deal with the abuse and that the battered woman faces a cycle of violence and psychological manipulation which, over a period of time, grows in intensity and frequency, culminating in the woman’s heightened sense of fear of the risk of death or serious injury. She explained how and why the battered woman had special knowledge of the imminence of an attack, and why retreat was not a reasonable alternative, and in the woman’s mind, there is no option to escaping the violence except by killing the abuser. The syndrome has been judicially recognized in Australia, Canada, New Zealand, United Kingdom and the USA—as a component of ‘grave and sudden provocation’, right to self-defence’, insanity or diminished responsibility, to explain the reasonableness of the accused woman’s actions against her violent and abusive partner (Hudsmith 1987; Nandy 2010; Braun 2016). In other words, although the defence of grave and sudden provocation conventionally warranted a spontaneous trigger for the attack by the accused, in its application to women subjected to domestic violence for a prolonged period of time, the continuous battering was considered a mitigating circumstance for reduced criminal responsibility of the accused woman. In India, Manju Lakra vs. State of Assam (2013) is a case that bore similar facts as Kiranjeet Ahluwalia’s case—the accused woman was regularly and severely assaulted by her drunk husband; one day, after he assaulted her on her head with a piece of wood, which led to a bleeding injury, she snatched away the wood, and hit him on several parts of his body, including his legs, head and back of his neck. Since he was drunk, he was unable to defend himself, and succumbed to his injuries. Thereafter she surrendered herself to police custody and made a confession before the judicial magistrate. The magistrate, at the time of recording her confession, observed visible injuries to her eye and head, which had been caused by the deceased husband on the night of the incident. The court also treated as important corroborative evidence, the statement of their nine year old daughter, that her deceased father would

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often return home drunk, and would quarrel with her mother and chase her around the tea estate with a Dao (traditional sword) in his hand in order to brutally assault her. The court clarified that the entire set of ‘grave and sudden’ provocative circumstances need not occur immediately preceding the murder, for the defence to be successfully applied. Applying the Battered Woman Syndrome, and the principle of cause and effect, the court explained as follows: Thus, the circumstances, pointed out above, lead to a probable belief that more than the intention to kill her husband, the intention of the accused was to put an end to the continuing violent acts of her husband and as a consequence whereof, she felt that nothing short of putting an end to the life of her husband would be a solution. The continuous turmoil in the domestic life of the accused-appellant, created by the violent conduct of the deceased husband, was potential enough to create a fear in the mind of the accused-appellant. The fear was not only real, because even before the date of occurrence, accused was beaten up by the deceased in a drunken condition, but also perceived in the sense of imminent threat to life and safety of the accused-appellant that tonight, too, she would have to bear the usual cruel treatment at the hands of her husband. Such perceived fear is possible only when continuous ill-treatment is shown to exist and such continuous ill-treatment did exist in the present case. (Para 114)

The slow build-up of the ‘volcano of strong resentment and rage’, which was being controlled and suppressed by the accused woman during the course of prolonged and intense domestic violence, and which eventually erupted into murder when triggered by the husband’s violent act, was given judicial recognition in this judgment. The court held that the accused woman’s action fell within the gamut of ‘grave and sudden provocation’ and that the offence she had committed was culpable homicide, and not murder. The Battered Woman Syndrome was also applied in Kalyani vs. State (2014). In this case, the woman was accused of murdering her husband with a big stone boulder at her home. She had been subjected to domestic violence for a prolonged period of time. The court observed that the husband was jobless, useless to the family, an alcoholic and would assault his wife every day. On the day of the incident, the husband had severely assaulted his wife; thereafter, he went to sleep, threatening to assault her further after he woke up. The court observed that the thought of his continuous beating haunted her; anticipating his assault once he woke up, she killed him with a boulder. The court referred to Kiranjeet Ahluwalia’s case (discussed above) and the Battered Woman Syndrome. While clarifying that the court was not justifying the killing, or giving a licence to wives to kill their erring husbands, it highlighted that at the time of commission of the crime, the woman was not able to control her mind, as her mind was ‘swayed by the continued barbarity perpetrated on her by her husband’. It therefore concluded that her husband had supplied the provocative circumstance which led the woman to take the extreme step of killing him. Its observations were for the limited purpose of finding merits in her bail application. On the grounds mentioned above, the court granted her bail. In Indian criminal law, on the face of it, the parameters established in Nanavati’s case appear to exclude situations of women killing their violent partners after years of tolerating domestic violence. However, judicial application of the Battered Woman

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Syndrome and an interpretation of the legal parameters through a battered woman’s perspective, as in the judgments discussed above, seem to have brought the issue back to centre stage. Scholars have argued in favour of a legislative reformulation of the defence of ‘grave and sudden provocation’ (Medarametla 2017).

Conclusion Indian criminal law largely consists of standards evolved through a male perspective of offences, with an inherent bias against women. The defences in criminal law are no exception. In recent years, Indian courts have attempted to infuse a gender perspective into the defence of unsoundness of mind and grave and sudden provocation, by examining specific experiences of women accused and scientific research undertaken by psychologists on factors pertaining to female criminality and mental health. Criminal jurisprudence in India is at a nascent stage with regard to two issues discussed above: application of Premenstrual Stress Syndrome (PMS) in the defence of unsoundness of mind, and the application of Battered Woman Syndrome to the defence of ‘grave and sudden provocation.’ There is a need to reflect on jurisprudential developments from a comparative perspective, so that Indian criminal law can benefit from a comprehensive discourse elsewhere on both the issues. Inclusion of PMS as a defence of legal insanity to women accused is a doubleedged sword. If its legal parameters are not carefully circumscribed, it could perpetuate the myth that all women are irrational, violent and potential criminals for a part of their menstrual cycle each month. The move could also inadvertently provide a boost to the dubious allegation that women misuse the law to their favour. Such a discourse is clearly disempowering to women and a dis-service to the women’s movements in India. On the other hand, in a small number of instances where a woman does experience an extremely severe form of PMS, which impairs her cognitive abilities to such an extent that she is unaware of the commission of the crime, or is unable to differentiate between the rightness and wrongness of it, it would be unfair to deny her the defence and hold her criminally responsible for an act that she did involuntarily. Likewise, the Battered Woman Syndrome introduces into the law on ‘grave and sudden provocation’ the women’s gendered experiences. At the same time, if its legal parameters are not clearly demarcated, courts would run the risk of labelling women as mentally ill, and shift the blame to the woman’s mental health. Instead, the focus ought to be on the patriarchy embedded in social structures and institutions, which create the dismal conditions for the woman to be subjected to domestic violence for a prolonged period in the first place, and counter the same. This article has argued that courts ought to tread carefully to avoid gender stereotyping, camouflaged as a gender perspective based on scientific research. Stereotyping is a stepping stone to creation of differences, denial of rights, discrimination and exclusion. In a patriarchal society where women face multiple forms of marginalization, interpretations of the law could potentially fuel newer, indirect and subtler

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forms of discrimination and perhaps, an exclusion of women from key decisionmaking or participatory processes in public life. This is compounded in the case of women facing mental health challenges due to stigma attached to mental health issues. Abundant caution is warranted to ensure that women who commit crimes are not labelled as mentally unstable or pigeonholed into responding in specific ways, thereby stigmatizing and marginalizing them further. There is a dire need for a more active conversation between relevant actors in the fields of criminal law, mental health, forensic sciences and gender studies, in order that a holistic perspective can be developed towards criminal responsibility of women facing mental health challenges.

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Kumari, V. (1999). Gender analysis of the Indian Penal Code. In A. Dhanda & A. Parashar (Eds.), Engendering laws: Essays in honour of Lotika Sarkar (pp. 139–160). Lucknow: Eastern Book Company. Manju Lakra vs. State of Assam 2013 SCC Online Gau 207: (2013) 4 GLT 333, at para 99. Medarametla, K. (2017). Battered women: The gendered notion of defences available. Socio Legal Review, 13(2), 108–129. Retrieved from http://www.sociolegalreview.com/wp-content/uploads/ 2018/04/Battered-Women-The-Gendered-Notion-of-Defences-Available.pdf. Mehra, M. (2013, May 5). Taking stock of the new anti-rape law. Retrieved from https://kafila. online/2013/05/05/taking-stock-of-the-new-anti-rape-law-madhu-mehra/. Nandy, P. (2010). Battered woman syndrome. SSRN Electronic Journal. https://doi.org/10.2139/ ssrn.1689521. Nuckols, C. C. (2013). Diagnostic and statistical manual of mental disorders: DSM-5 (pp. 37, 39). Arlington, VA: American Psychiatric Association. Pathare, S. (2017, April 23). Widely cited, but still undefined. The Hindu. Pathare, S., Nardodkar, R., Shields, L., Bunders, J. F., & Sagade, J. (2015). Gender, mental illness and the Hindu Marriage Act, 1955. Indian Journal of Medical Ethics, XII (1), 7–13. Retrieved from https://ijme.in/articles/gender-mental-illness-and-the-hindu-marriage-act-1955/?galley=html. Prasad, A. (2018, August 9). Rajasthan high court’s Regressive ruling: Defence of insanity to include PMS. Retrieved from https://feminisminindia.com/2018/08/09/rajasthan-high-court-ruling-pmsinsanity/. Press, M. P. (1983). Premenstrual stress syndrome as a defence in criminal cases. Duke Law Journal, 32(1), 176–195. R vs. M’Naghten (1843) 8 E.R. 718. Raha, S. (2009, May). Protecting women with disabilities from violence. Retrieved from http:// infochangeindia.org/disabilities/64-disabilities/backgrounder/7742-protecting-women-withdisabilities-from-violence. Ramanathan, U. (1999). Images (1920–1950): Reasonable man, reasonable woman and reasonable expectations. In A. Dhanda & A. Parashar (Eds.), Engendering laws: Essays in honour of Lotika Sarkar (pp. 33–70). Lucknow: Eastern Book Company. Raveesh, B. N., Anil, K. M., & Narendra, K. S. (2013). Law and psychiatry in India: An overview. Journal of Forensic Science & Criminology, 1–6. Retrieved from http://www.annexpublishers. com/articles/JFSC/volume-1-issue-2/Law-and-Psychiatry-in-India-An-Overview.pdf. Regina v. English, an unreported decision of the Norwich Crown Court on November 10, 1981. Regina vs. Craddock 1981 1 C.L. 49. Regina vs. Kiranjeet Ahluwalia 1992 (4) All ER 889: (1993) 96 Cr App R 133. Sadoff, R. L. (1987). The insanity defence in criminal law. In B. E. Ginsburg & B. F. Carter (Eds.), Premenstrual syndrome (pp. 73–80). Boston: Springer. Scales, A. (2006). Legal feminism: Activism, lawyering and legal theory (pp. 83–99). New York, NY: New York University Press. Singh, H., Walia, R., Gorea, R. K., & Maheshwari, A. (2004). Premenstrual syndrome (PMS): The malady and the law. Journal of Indian Academy of Forensic Medicine, 26(4), 129–131. Smith, P. (2010). Feminist jurisprudence. In D. M. Patterson (Ed.), In a companion to philosophy of law and legal theory (pp. 290–298). West Sussex: Blackwell Publishing. Smt. Suljina Dhan vs. State of Assam 2018 SCC Online Gau 645. The Hindu Marriage Act. (1955). Retrieved from https://highcourtchd.gov.in/hclscc/subpages/pdf_ files/4.pdf. United Nations Convention on the Rights of Persons with Disabilities. (2006). Retrieved from https://www.un.org/disabilities/documents/convention/convention_accessible_pdf.pdf. United Nations. (2014). Retrieved from https://www.ohchr.org/Documents/Events/WHRD/ WomenRightsAreHR.pdf. Walker, L. E. (2017). The battered woman syndrome (4th ed.). New York, NY: Springer Publishing Company.

Part III

Gendering Mental Health: Field Narratives

Chapter 11

Psychosocial Rehabilitation—The Past, Current Approaches and Future Perspectives Roy Abraham Kallivayalil and Sheena Varughese

Introduction Mental health is cherished by all. Prevention of mental illness, its proper management and the promotion of mental health are of paramount importance. Mental, physical and social well-being is vital strands of life that are closely interconnected and interdependent. Mental disorders are characterized by abnormalities of cognition, emotion and behaviour. People with these disorders are subjected to social isolation, poor quality of life and increased mortality, which leads to increased social and economic burden. About 450 million people suffer from mental disorders. (WHO The world health report 2001—Mental Health, n.d.). Mental and neurological disorders account for 13% of the disability-adjusted life years (DALYs) lost due to all diseases and injuries in the world (World Health Organization 2004). Severe mental illness like schizophrenia imposes new challenges on our society. Living with such an illness is often painful and difficult. This is especially so in the low- and middleincome (LAMI) countries where there are severe resource constraints, especially for infrastructure and mental health manpower. The sufferers sometimes face isolation and neglect. Persons with severe mental disorders, such as schizophrenia and bipolar affective disorders, represent a heterogeneous group with different problems and varying levels of needs. More often, the severe mental disorder tends to run a chronic course and has a devastating impact on the person’s functioning. Due to this global impact, it affects not just the individual, but also his family and in turn the community at large. The deficiency in care facilities and family force many of the mentally ill to lead a life in the streets in low- and middle-income (LAMI) countries including India. Homeless mentally ill individuals reflect the current situation in the society of He is President of World Association of Social Psychiatry (Paris) and the Secretary General of the World Psychiatric Association, Geneva. R. A. Kallivayalil (B) · S. Varughese Department of Psychiatry, Pushpagiri Institute of Medical Sciences, Thiruvalla, Kerala, India e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2020 M. Anand (ed.), Gender and Mental Health, https://doi.org/10.1007/978-981-15-5393-6_11

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the limited mental health care available in the public sector, lack of coordination of different caring groups and the absence of welfare system to meet the needs of mentally ill individuals and their families (Sheth 2005). Psychiatric rehabilitation is an essential component of the management of persons with chronic mental illness along with pharmacological management. It now universally accepted the importance of rehabilitation interventions as a part of the treatment from the very first meeting with the patient. They have to be individually tailored and socioculturally appropriate (Gopinath and Rao, n.d.). The goal of psychiatric rehabilitation is to help individuals with serious mental illness to develop the emotional, social and intellectual skills needed to live, learn and work in the community with the least amount of professional support (Anthony et al., n.d.). Therefore, outcome measures like social relationships, work, leisure time, quality of life and family burden are of major interest to the mentally disabled individuals living in the community. The essential elements of the psychiatric rehabilitation approaches have been changed over a century highlighting the progression through different developmental phases. The 1980s was a decade of transition between the era of de-institutionalization and the era of rehabilitation. The purpose of the rehabilitation is to help the persons with long-term disabilities to improve their functioning either by developing the skills or by strengthening the support. In the decade of the 1990s, psychiatric rehabilitation began to take its position as a viable, credible service. Psychiatric rehabilitation is the only mental health service that specifically focuses on improving role performance and is based on a conceptual model that recognizes the negative consequences of severe mental illness in terms of impairment, dysfunction, disability and disadvantage.

Mental Health and Mental Illness Mental health is a state of successful performance of a mental function, resulting in productive activities, fulfilling relationships and the ability to cope with adversity and adapt to change. Mental health and mental illness are considered as points on a continuum. Mental illness or mental disorder significantly affects the person’s feelings, thinking, behaviours and interaction with other people. A mental health problem also affects these domains of a person but to a lesser extent. Mental health problems are more common and include the stresses of life, which temporarily affects mental health. Even though mental health problems are less severe, they may develop into mental illness if they are not dealt with effectively. The psychotic disorders like schizophrenia and bipolar affective disorders represent a heterogeneous group. These disorders tend to run a chronic course and have a devastating impact on a person’s functioning. Due to this global impact, it affects not just the individual, but also his family and, in turn, the community at large. Common mental disorders like depression, anxiety and adjustment disorders are much less disabling. The ICD-10 (1992) and DSM 5 (2013) give a detailed account of the classification of mental disorders.

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Etiological Factors Mental disorders are often considered as a consequence of the interplay between biological, psychological and sociocultural factors. Bio-psychosocial factors are involved in the cause, manifestations, course and outcome of health and diseases including mental disorders (Engel 1977).

Care of the Mentally Ill: Mental Health Services The care of the mentally ill plays an important role in the process of recovery for the mentally ill. The mental health services include a promotion, prevention and treatment approaches. These interventions should be given to all irrespective of risk for mental health problems. Mental health promotion: It is shown to be an effective strategy to reduce the burden of mental disorders. Mental health promotion activities enable optimal psychological and psycho-physiological development, which in turn helps to achieve positive mental health and to improve quality of life. Mental disorder prevention: Preventive intervention focuses on reducing risk factors and improving protective factors. Mental disorder prevention aims at ‘reducing the incidence, prevalence, recurrence of mental disorders, the time spent with symptoms or the risk condition for a mental illness, preventing or delaying recurrences and also decreasing the impact of illness in the affected person, their families and the society’ (Haggerty and Mrazek 1994). Treatment approaches: Most treatments fall under two general categories, biological and psychosocial. The common biological treatment is pharmacological, and much less commonly electroconvulsive therapy (ECT). Comprehensive care for mental disorders involves not only drug treatments, but also the provision of ongoing support, valid information and, where appropriate, therapies or rehabilitative strategies.

Psychosocial Rehabilitation Psychosocial rehabilitation is a process, which provides opportunities for persons who are impaired, disabled, handicapped by mental disorders, to reach an optimum level of independent living in the community (Rössler 2006). It is initiated by mental health professionals, in collaboration with the patient’s families and community, and supported by the policy planners. It aims to develop and implement an individualized programme that helps to maximize the patient’s strengths and to minimize his disabilities in the area of socio-occupational functioning, centring around the philosophy of mobilizing and utilizing resources available to the community, with the final

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objective of mainstreaming the patient. The overall goal of psychiatric rehabilitation is to assure that persons with psychiatric disabilities can perform those cognitive, emotional, social, intellectual and physical skills needed to learn, live, work and function with a few symptoms as possible in the community. Different dimensions had been used to describe the long-term consequences of major mental disorders. The World Health Organization in 1980 published a useful tool—the International Classification of Impairments, Disabilities, and Handicaps (ICIDH) (9241541261_eng.Pdf,n.d.). It has been recently revised, and the revised International Classification of Functioning, Disability, and Health (ICF) includes certain changes (World Health Organization 2001). Primarily, there was a change from negative descriptions of impairments, disabilities and handicaps to neutral descriptions of body structure and function, activities and participation. The inclusion of a section on environmental factors as part of classification was another major change. This highlights the importance of environmental factors to create a disability or restore functioning, depending on whether the environmental factor is a facilitator or a barrier. Psychosocial rehabilitation services are collaborative, person-centred and individualized. These services include ways to foster social interaction, to promote independent living and to encourage vocational performance (Cook and Jonikas 1996). The concept of psychosocial rehabilitation is associated with social psychiatry. Bennet (1983) described that the term rehabilitation has been borrowed by psychiatry from physical medicine (Bennett: The historical development of rehabilitation…—Google Scholar).

Core Principles of Psychosocial Rehabilitation International Association of Psychosocial Rehabilitation Services proposed the following principles of psychosocial rehabilitation (Smith: Review of an introduction to psychiatric rehabilit…—Google Scholar). 1. 2. 3. 4. 5. 6. 7. 8.

Recovery is the ultimate goal of psychosocial rehabilitation. Interventions must facilitate the process of recovery. Helping people to re-establish normal roles in the community and their reintegration into community life. To facilitate the development of personal support networks. Facilitating an enhanced quality of life for each person receiving services. The assertion that all people can learn and grow. People receiving services have the right to direct their affairs, including those that are related to their psychiatric disability. All people are to be treated with respect and dignity. Making conscious and consistent efforts to eliminate labelling and discrimination, particularly discrimination based on a disabling condition.

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9. 10. 11. 12. 13.

14. 15.

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Culture and/or ethnicity play an important role in recovery. They are sources of strength and enrichment for the person and the services. Interventions building on the strengths of each person. Services are to be coordinated, accessible and available as long as needed. Services are to be designed to address the unique needs of each individual, consistent with the individual’s cultural values and norms. Actively encourage and support the involvement of persons in normal community activities, such as school and work, throughout the rehabilitation process. The involvement and partnership of persons receiving services and family members are essential ingredients of the process of rehabilitation and recovery. Constantly striving to improve the services being provided.

Rehabilitation has been described by Wing (1978) as having two components, enabling and caring: enabling is the sense of helping the individual to lead a normal life as far as possible in spite of his limitations; caring is helping to create various kinds of protected or supported environments adapted to these limitations (Wing and Olsen 1979).

Development of Rehabilitation Services in India The development and growth of psychosocial rehabilitation in India can be divided into two stages, pre-independence period and post-independence period.

Pre-independence Period The initial phase consists of a pre-independence period, where most of the services were hospital-based and largely confined to the government settings. There was a mental hospital at Dhar, near Mandu, in Madhya Pradesh, established by Mohammed Khilji in the fifteenth century between 1436 and 1469 A.D. The lunatic asylums in India were established after the British East India Company came to India. The main aim of this was to separate the mentally ill from society. The Indian Lunatic Asylum Act, 1858, was sanctioned by the British Government which was in force in India during the late nineteenth century. In 1895, Dr. W.R. Rice, I.M.S. stressed the importance of occupational therapy for persons with mentally ill in the lunatic asylum as part of psychiatric treatment, after surveying the functions and conditions of lunatic asylums in India. It was a landmark in the field of psychosocial rehabilitation in India. There was a rehabilitation programme for the mentally ill at Mysore Lunatic Asylum, between the 1870s and 1890s. In this programme, persons with mental illness were involved in the field of agriculture and the programme was called ‘Work Therapy’. In the early twentieth century, a major revolution occurred in the field

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of psychosocial rehabilitation. The Indian Lunacy Act was enacted in 1912 by the British Government. The word lunatic asylum was replaced by the name ‘mental hospital’. In 1929, the Indian Association for Mental Hygiene was founded by Dr. Barkeley Hill with a major objective to encourage the study of mental health in the community. The establishment of the Indian Psychiatric Society in 1947 can be considered as the most important milestone in the history of the mental health movement in India.

Post-independence Period (a) First Phase (1947–1975) The major progress of psychosocial rehabilitation happened in the post-independence period. Evidence shows that there was a Department of Occupational Therapy for the mentally ill at Central Institute of Psychiatry (CIP), Ranchi, in 1950, the best occupational therapy unit in India. Even now, most of the hospitals do not have structured rehabilitation services. The involvement of the family in the psychiatric treatment was initiated by Dr. Vidya Sagar in 1954 at Amritsar Hospital in Punjab. He encouraged the family members to stay in the hospital. It gave motivation to the family members to understand the illness of their loved ones. The importance of the rehabilitation programme for the mentally ill was highlighted during the stay in the ward. In 1960, the first day care centre for the mentally ill was established by the All India Institute of Mental Health, Bangalore. It offered various vocational trainings such as carpentry, weaving, tailoring and candle making. In the 1960s, a Mental Health Centre was started at Christian Medical College Hospital at Vellore, Tamil Nadu, wherein an occupational therapy was started too. In 1962, the Day Hospital was started at the Institute of Mental Health, Madras. It offered different vocational trainings for the mentally ill. In 1964, the first voluntary organization for persons with mental illness was established by a group of people at Bangalore, called Medico Pastoral Association (MPA). The organization had initially organized counselling services and group activities. Later as they understood the felt need of the group of persons, halfway homes were established by the association in 1972 which was first of its kind in India. In the 1970s, a home-based rehabilitation programme for schizophrenics was started by NIMHANS, Bangalore. It was focused on patients who were not able to avail of the mental health facilities. The reasons for the same were the distance of the hospital from home, social stigma, difficulty in drug compliance and the inability of the family in understanding the illness. The interventions such as counselling, psychoeducation, home-based rehabilitation activities and identifying important signs of relapse were given to the family members by a trained nurse. (1970 after 1972 is not changed as it may change the meaning).

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(b) Second Phase (1976–2005) The Alma Ata Declaration was proclaimed in 1978. There were many components in the declaration, and the seventh component was the promotion of mental health through the primary healthcare system in the community. It focused on the care of the mentally ill persons in the community. United Nations celebrated the International Year of Disabled in 1981. This gave a lot of impetus to the professionals to offer community-based rehabilitation services for people with disabilities. In 1982, the National Mental Health Programme (NMHP) had its inception by the Government of India. It was a landmark in the field of psychosocial rehabilitation. It was implemented with three objectives, which were: to ensure the availability of minimum mental health care for all, to encourage the application of mental health knowledge in general health care and to promote community participation in the mental health services. The last objective of the programme had three components, and the second component was emphasized on psychiatric rehabilitation for the mentally ill persons in the community. In 1983, the Schizophrenia Care and Research Foundation (SCARF) was established by Dr. Sarada Menon at Madras to provide various skills trainings for the mentally ill. The organization launched the community-based day care centre in 1985, near Chennai, in response to the needs of the community. It has been offering various vocational trainings such as printing, tailoring, mat weaving, soap making and candle making. In 1985, the community-based rehabilitation programme was launched by the WHO. Initially, it focused on people with disabilities like locomotor disability, blindness, and hearing impairment and multiple disabilities and later into the field of mental health. In 1986, The Richmond Fellowship Society (India) was established at Bangalore, to provide skills training for the mentally ill and develop the professional manpower in the field of psychosocial rehabilitation. In 1987, the Mental Health Act was enacted by the Government of India after persistant efforts by the Indian Psychiatric Society and other mental health professionals. Based on experience gained by the Richmond Fellowship Society and felt need of the community, the organization started the model halfway home in 1989, long-stay group home in 1995 and community-based day care with vocational training facilities in 1997 at Bangalore. In 1987, the Mental Health Act was enacted by the Government of India after persistent efforts by the Indian Psychiatric Society and other mental health professionals. In December 1995, People with Disability Act (equal opportunity, protection of rights, full participation) was enacted by the Government of India and was implemented in February 1996. In 1999, the National Trust Act was enacted and implemented by the Government of India. This act is for persons with autism, cerebral palsy, mental retardation and multiple disabilities. (tried to follow the list of hierarchy, however there are few instances where we loose the thread in the sentances.) Global Initiatives: it was taken up by the World Psychiatric Association (WPA), World Association for Social Psychiatry (WASP), World Association for Psychosocial Rehabilitation (WAPR), etc. The Madrid Declaration on Ethical Standards for

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Psychiatric Practice adopted by the WPA General Assembly in 1996 is a milestone. WPA has also established a Section on Psychiatric Rehabilitation. WASP has a Section on Community Mental Health which focuses on rehabilitation.

Psychiatric Rehabilitation in India Psychiatric rehabilitation in India is in a dynamic phase of growth. It can be considered in three different sectors. These are hospital-based initiatives, non-governmental organizations (NGOs) and NGO community initiatives. Hospital-Based Initiatives: These were initially restricted to the government mental hospitals and institutes of mental health. Main rehabilitation facilities were occupation therapy and were mainly ward-based activities, largely confined to the needs of the hospitals. Hospital work likes cleaning and assisting nurses were very common in hospitals. There were improvements following the recommendations of National Human Rights Commission (NHRC) in 1999, especially at the hospitals in Gujarat, Kerala and Madhya Pradesh. There has been a gradual shift from occupational activities towards productive and purposeful activities. Patients started to get incentives for their work. Many of the hospitals have started attached day care centres and halfway homes in their premises. In the day care centres, most of the patients were with greater disability and those from lower socio-economic status. The main reason that these efforts have not been replicated in many hospital settings is due to the paucity of mental health professionals. Non-governmental Organization Initiatives: There are different types of organizations involved in a range of rehabilitation services for the mentally ill. They have a reasonable infrastructure and a well-structured programme in place. Patients under these rehabilitation programmes are those who have recovered from the acute illness and who are on maintenance medication. They provide both residential facilities and a day care facility. Home for the Homeless: There has been relatively less visible community initiative for the mentally ill. A novel approach has originated in Kerala. The homeless mentally ill are taken in from the streets and are provided with shelter, clothes and medicines by ordinary families. These families are from the low and middle socioeconomic strata and are driven by religious faith. The expenditure of these initiatives is met through donations, and few centres are equipped with adequate infrastructure and good care. The majority of the centres are aware of the principles of care for the mentally ill and have a visiting psychiatrist to provide the necessary care. Once they recover, their families are traced and are rejoined with them. Those who are not accepted by the families remain at the centre. One such centre is at Pala, Mariasadanam, Kerala, which has an orchestra and drama troupe consisting of recovered persons and has completed more than 400 stage shows. These centres also perform regular public awareness programmes. An intervention study was done to assess the effectiveness of the low-cost psychosocial rehabilitative model in this centre and was found to be effective. This could serve as a model not only for other similar centres

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in India but also for other low- and middle-income group countries (Kallivayalil and Sudhakar 2018). Community involvement in such centres will reduce the stigma associated with mental illness. NGO-Community Initiatives: Community-based activities have largely come through non-governmental organizations (NGOs). The quality of care varies markedly across different centres. Financial constraints are the main limiting factor. Community-based rehabilitation services are very appropriate in the Indian culture settings, as the social and community bonds are quite strong and deep-rooted. The upcoming view is that community-based rehabilitation programmes for the mentally ill should integrate with an existing community development programme so that resources are well used. There is a need for better partnerships between mental health professionals, NGOs and community services.

Psychiatric Rehabilitation: Current Approaches and Future Perspectives All patients suffering from severe mental illness (SMI) require rehabilitation. The main group consists of patients with persistent psychopathology, frequent relapses and those who have social maladaptation. Up to 50% of patients with severe mental illness also carry a diagnosis of substance abuse, and many of them will have a history of attempted suicide. These are the patients who represent a difficulty to treat patient population.

Concept of Rehabilitation The philosophy of psychiatric rehabilitation is based on two intervention strategies. First is the person-centred, targeted to develop the patient’s skills in interacting with a stressful environment. The second strategy is ecological, targeted to develop the environmental resources to reduce potential stressors. The psychiatric rehabilitation is regularly carried out under real-life situation. Hence, rehabilitative practitioners need to take into consideration the real-life situations that the affected individual is likely to encounter in his or her day-to-day living (Bachrach 2000). The second step is to help the disabled persons to identify their personal goals and readiness to change by motivational interviews (Liberman et al. 2004). Irrespective of the degree of psychopathology, later the rehabilitative processes focus on the patient’s strengths, with the notion that ‘there is always an intact portion of the ego to which treatment and rehabilitation efforts can be directed’ (Lamb 1982). Psychiatric rehabilitation concentrates on patient’s rights as a respected partner and validates their involvement and self-determination in all aspects of the treatment and rehabilitation processes. The rehabilitation processes also give importance to the concept of recovery (Farkas

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et al. 2005). The most important factor which facilitates recovery is found to be a therapeutic alliance. Usually, individuals with chronic mental illness lose close, intimate and stable relationships in the course of their illness. Recent research has suggested that social support is associated with recovery, greater life satisfaction and enhanced ability to cope with life stressors (Corrigan et al. 2005).

Current Approaches Individuals with psychiatric disabilities have an equal right to have aspirations as individuals without disabilities. They have the right to be respected as an autonomous individual and lead a life as normal as possible. They have the right to have: (1) their own housing, (2) education and meaningful work career, (3) satisfying relationship, (4) community life participation. (1) Housing: Providing sheltered housing was one of the first steps in the process of de-institutionalization. Once in supported housing, the majority who reside in sheltered housing, thereby have less chances of being hospitalized. (2) Work: Vocational rehabilitation has been the core of psychiatric rehabilitation since its beginning, supporting the beneficial effects of work in mental health. Vocational rehabilitation is based on the assumption that work improves not only the activity but also the quality of life and self-esteem, which in turn improves the adherence to the rehabilitation of individuals with impaired insight. Employment helps the individual to integrate into society (McElroy 1987). Today, supported employment (SE) is the most promising rehabilitation model. Here, individuals are placed in competitive employment according to their choices, as soon as possible, and provide all support to maintain their position. It has been found that those who acheived long-term employment through SE had better cognition, quality of life and symptom control. However, long-term impacts remain unclear as most of the studies only evaluated for a shorter period. After all, we have to realize that the integration of an affected individual is dependent not only on their ability to fulfil their work role or provision of sophisticated vocational training but also on the willingness of society to integrate them. (3) Building Relationships: Social skill training in psychiatric rehabilitation has become very popular. Robert Liberman was the most prominent proponent of skills training, who had designed a structured skill training since the mid-1970s (Liberman 1988). Skill training contains different modules with different topics. The modules focus on medication management, symptom management, substance abuse management, basic conversational skills, interpersonal problemsolving, recreation and leisure, workplace fundamentals, community re-entry and family involvement. The skills are taught by the role play, demonstration videos and homework assignments (Liberman and Kopelowicz 2002). Social and community functioning improves when the trained skills are relevant to the patient’s daily life hence, long-term training is needed for positive effects.

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(4) Keeping Relationships: The burden of care has increasingly fallen on the family members as a consequence of de-institutionalization. Caregiving imposes considerable adverse health effects, including high levels of stress and depression and low levels of subjective well-being, physical health and self-efficacy. All family members are not equally capable of providing care to their disabled family member, and caregivers experience higher levels of a burden when they have poor coping skills and decreased social support. Family is an important natural setting that facilitates the recovery of functioning. However, quite often family members are blamed for any patient problems, their contribution to care is not appreciated, and they are not sufficiently informed about their relative’s health condition. This, in turn, leads to frustration and resentment among relatives considering the physical, financial and emotional family burden. Family interventions are effective in reducing family burdens, lowering relapses and improving functioning. We have to be aware that family interventions differ in different cultures. (5) Community Life: Stigma and discrimination often negatively affect the lives of a mentally ill person. This includes demoralization, low quality of life, unemployment and reduced social networks (Mueller et al. 2006). Based on research in this area, several strategies are developed to fight stigma and discrimination. All these initiatives make an effort to reintegrate the mentally ill into community life, and it must be accompanied by measures on the societal level. Effective psychiatric rehabilitation requires individualized and specialized treatment. Even though a variety of services are available, they are poorly linked and sometimes duplicated. It focuses on the need for services to be coordinated and integrated so that each involved professional would concentrate on different aspects of the same patient. Therefore, the concept of case management (CM) originated, which focuses on all aspects of the social and physical environment. The core elements of CM are the assessment of patient needs, the development of a comprehensive service plan for the patients and the arrangement of service delivery (Rössler et al. 1992). Over the past two decades, different models of CM have developed which exceeds the original goal of CM today, and most case managers provide direct services in the patient’s environment. This model is called intensive case management (ICM). It is difficult to distinguish between ICM and assertive community treatment (ACT). Stein and Test have developed ACT in the 1970s, as a community-based alternative to hospital treatment for persons with severe mental illness. The ACT is characterized by an intervention which is mainly provided in the natural environment of the disabled individuals (Scott and Dixon 1995). ACT model was found to be more effective when compared to standard care. Psychosocial rehabilitation techniques address the social isolation and avoidance of social interactions that are the hallmark of many severe and persisting mental disorders and trauma.

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Psychiatric Rehabilitation: Kerala Experience Kerala is considered a model for health care, especially for being cost-effective. The health indices of the state like infant mortality, maternal mortality and life expectancy are comparable to many Western countries. But the treatment of the severely mentally ill posed new challenges. The government infrastructure was wholly insufficient. It was at this time, nearly three decades back, some non-governmental organizations (NGOs) boldly came forward to shoulder this responsibility. We had the opportunity to work with two of them—‘Navajeevan’ at Kottayam and ‘Mariasadanam’ at Pala. The Department of Psychiatry at Government Medical College, Kottayam, provided free psychiatric services to Navajeevan. Similarly, the Department of Psychiatry at Pushpagiri Institute of Medical Sciences, Thiruvalla, makes regular visits and provides necessary psychiatric care at the ‘Mariasadanam’. The mentally ill belonged to both sexes, with women forming the majority. In these centers lay volunteers were taking up the care and rehabilitation of the severely ill. They had little support from the governments but relied almost entirely on voluntary pubic donations to cover their expenses. (i) We researched the treatment model at ‘Mariasadanam’. Besides medical care, music, drama, theatre, cooking, embroidery, tailoring, carpentry and other rehabilitation measures were implemented. The improvement in the quality of life and reduction in disability status have been statistically significant. This helped in the early discharge of the inmates from the rehabilitation centre. Early discharge, reduced treatment costs, improvement in the quality of life, reduction in disability status and early rehabilitation will have a positive effect in reducing the burden of disease in the society. Our results shed light on the fact that rehabilitative techniques can be employed in a centre even when there are minimal resources. Those individuals who remained at the rehabilitation centre after the intervention phase showed significant improvement in their quality of life and disability status. Some of the highlights are as follows: (i) (ii) (iii) (iv) (v) (vi)

No consultation fees or charges are levied. Postgraduate residents are present. Community psychiatry training is provided. Psychoeducation for the volunteers is mandatory. Various types of rehabilitation measurers are enabled. Outreach community services are available (Kallivayalil and Sudhakar 2018).

We do believe collaboration with NGOs will be a lasting model for mental health care in LAMI countries.

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Conclusion The psychiatric disorders are long-lasting illness, especially major mental disorders. It affects the functioning of human beings and finally leading various mental disabilities over some time. To deal with mental disability areas such as self-care, work habits, time management, money management, interpersonal relationship, household activities and attending social functioning, there is a need for separate therapeutic interventions along with psychopharmacology called psychosocial rehabilitation. The history of psychosocial rehabilitation has its long-lasting roots that have been explained above with available resources. It sheds light on the field of psychosocial rehabilitation to fill the lacunas and will help the mental health professionals and other allied professionals with knowledge and skills for practice. Utilization of the trained personnel will help in the smooth functioning of the existing services which in turn will develop an interest to initiate more innovative strategies of rehabilitation that suit our culture. The perspective of the public, regarding the psychosocial rehabilitation, can be attended to a great extent with psychoeducation, public awareness programme and by involving the caregivers in the treatment programme. Today, research supports the scientific basis of treatment. This evidence, taken in its entirety, points to the value of treatment approaches combining medications with psychosocial treatments, including psychological interventions, family interventions, supported employment, assertive community treatment and skills training. Currently, available treatment technologies, when appropriately applied and accessible, should provide most patients with significant relief from psychotic symptoms and improved opportunities to lead more fulfilling lives in the community. An essential ingredient to cover the enormous mental health gap would be in collaboration with NGOs.

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Chapter 12

Homelessness and Women Living with Mental Health Issues: Lessons from the Banyan’s Experience in Chennai, Tamil Nadu Lakshmi Narasimhan, K. V. Kishore Kumar, Barbara Regeer, and Vandana Gopikumar

Background The last decade has brought a remarkable degree of attention globally to importance of mental health as a public health priority and Sustainable Development Goal (SDG) (WHO 2016). Mental disorders are responsible for an estimated 13% of years lost due to ill health (Vigo et al. 2016). One hundred and fifty million Indians, or 1 out of every 10 individuals, are living with some form of mental health issue (Gururaj et al. 2016). Less than 10% of people with common mental disorders and only 40–50% of people with schizophrenia are estimated to be accessing any form of care (Patel et al. 2016). Mental health is chronically underfunded and under-resourced in India. While the District Mental Health Programme (DMHP) initiated in 1982 has finally been extended to cover a majority of the districts in the country, it predominantly offers specialist camps failing to offer much of the envisioned community-based care under the limited public health infrastructure (Isaac 2018). State-run mental health hospitals and psychiatric units in district hospitals in India offer between them 20,000 beds in the public sector, less than 2 for every lakh of the country’s population (Murthy et al. 2016). The recent report by the National Human Rights Commission that has been monitoring the quality of mental hospitals following a Supreme Court L. Narasimhan (B) The Banyan Academy of Leadership in Mental Health, Thiruvidanthai, India e-mail: [email protected] K. V. Kishore Kumar National Institute of Mental Health and Neuro-Sciences (NIMHANS), Bangalore, India B. Regeer Athena Institute, VU University Amsterdam, Amsterdam, Netherlands V. Gopikumar School of Social Work, Tata Institute of Social Sciences (TISS), Mumbai, India © Springer Nature Singapore Pte Ltd. 2020 M. Anand (ed.), Gender and Mental Health, https://doi.org/10.1007/978-981-15-5393-6_12

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directive over a decade earlier indicates that despite infusion of investments as centres of excellence in infrastructure, there is a long way to transforming several hospitals into human rights compliant spaces of care (Murthy and Isaac 2016). Further services are left deficient by lack of human resources, in terms of quantity with insufficient psychiatrists, social workers and psychologists (Mental Health ATLAS 2017 Member State Profile—India 2017) and quality as staff work and train under overburdened systems that persist with simplified medicalized orientation (Jain and Jadhav 2009). Within this sobering scenario, homeless people with mental illness represent an even more marginalized population. Poverty, mental illness and homelessness interact in a vicious, unrelenting, often recurrent cycle. Poverty represents a significant risk factor for mental health issues and for rendering people with mental illness from a particular stratum and marginalized groups homeless (Folsom et al. 2005; Hudson 2005; Lund and Cois 2018; Read 2010; Sullivan et al. 2000). Read (2010) posits that social causation explains how poverty causes psychosis while social drift accounts for how poverty is involved in its maintenance. A systematic review of studies conducted in Western countries found the prevalence of serious mental disorders to be significantly higher among homeless people when compared to the general population (Fazel et al. 2008). Gender inequalities embedded in patriarchal structures are implicated in pathways to homelessness among women. While the substantive body of the literature on homelessness and mental health, predominantly from the West, focuses on men, some scholars have pointed out the differing experiences of homelessness among men and women necessitating unique responses (Fotheringham et al. 2014; Hagen 1987; Klodawsky 2006). Complex, multiple trauma accompanies the experiences of homeless people with mental illness, sexual abuse beginning from childhood and violence in intimate partner relationships (Browne 1993; Hamilton et al. 2011; Padgett et al. 2006; Padgett et al. 2012; Zugazaga 2004). Such trauma is often further exacerbated when women with mental illness move away from their homes, to escape violence only to live in adverse environments on the streets, with limited access to food, safety and in a state of compromised health. Ethnographic observations by Parkar et al. (2003) in Mumbai showcase how environmental and social contexts and intersecting, gendered afflictions play a substantive role in shaping up mental health responses. Marrow and Luhrmann (2012) juxtapose the possibility of women with mental illnesses, in post-colonial India, being abandoned, not necessarily on the streets, but within domestic spheres, where they are made to exist, tied down without treatment possibilities, due to lack of mobility, care and pervasive culture. More recently, Trani et al. (2015) found enhanced risks for women from disadvantaged castes with mental illness to experience downward trajectories into multidimensional poverty as a consequence of stigma compared to male controls. In a resource-scarce environment and added invisibility and marginalization due to gender, women caught at the intersection of homelessness and mental illness have limited options of long-term institutionalization in state mental hospitals, criminalization under state beggary acts to continually re-enter beggar’s homes or life on

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the streets. A multistakeholder national-level survey of people living for a year or more across 43 state-run psychiatric facilities in India during the months of August 2018–February 2019 found that nearly half of the estimated long-stay service users in state mental hospitals in India have a history of homelessness (Narasimhan et al. 2019). The same survey points out that more women (54.26%) than men (45.74%) had been institutionalized (see Fig. 12.1). Desai et al. (2010) point out that supported admission of homeless people with mental illness is an existent truth, wherein ethical dilemmas are conflated with a pressing need to provide clinical services leading to restrictive care, chronicity and subsistence of illnesses. Yet for social justice to be Proportion of Men vs Women in Long-stay Service-Users at State Psychiatric Hospitals Source: National Strategy for Inclusive and Community Based Living for Persons with Mental Health Issues (2019), The Hans Foundation

Men

Women

National Tamil Nadu West Bengal Odisha Goa Meghalaya Maharashtra Jammu & Kashmir Tripura Haryana Kerala Andhra Pradesh Assam 0%

20%

40%

60%

80%

100%

Fig. 12.1 Proportion of men versus women in long-stay service-users at state psychiatric hospitals. Source National strategy for inclusive and community based living for persons with mental health issues (2019), The Hans Foundation

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truly achieved in this country, their complex histories and needs demand a humanistic and comprehensive response that enables them to participate fully in their lives and society. Civil society responses to issues of homeless people with mental illness in India, such as Iswar Sankalp (Kolkata), Anjali (Kolkata), Koshish (Mumbai), Ashadeep (Guwahati) and some state-run institutions such as NIMHANS (Bangalore), IHBAS (Delhi) and Government Mental Hospital (Ahmedabad) offer a sliver of hope for homeless people with mental illness to more than just exist. Recently, some literature describing outcomes from services delivered by psychiatric units in medical colleges has emerged (Gowda et al. 2017; Singh et al. 2016; Tripathi et al. 2013). However, Saraceno et al. (2007) note how such initiatives are not complemented by a ‘swelling public opinion on mental health needs’ which can materialize as the much needed catalysing push for greater bureaucratic action. The Mental Health Act of 1987 has been replaced with the newer progressive legislation, and the Mental Healthcare Act 2017 intended to be compliant with the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD). Mental health features more substantively beyond being merely listed as a disability in the new Rights of Persons with Disabilities Act 2017 enshrining the right to live in the community with flexible, personalized supports. The mental health policy formulated a few years ago dedicates a section to the issue of homelessness among people with mental illness. These developments present an unprecedented opportunity in the form of intent. Besides catalysing public opinion towards action, what implications may be drawn from local implementations to shape public policy and practice and bridge the know-do gap in working with this unique constituency? In this article, we describe the work of The Banyan in Chennai, most familiar to us through our professional association, to answer this question.

The Banyan: Evolution of a Continuum of Care The Banyan, founded in 1993, began as a crisis intervention and rehabilitation centre for homeless women with mental health issues and has over the last twenty-five years expanded to offer a range of comprehensive mental health solutions for people who are either homeless or living in a state of abject poverty. This first shelter facility offered a residential community in a home, family-like environment to the niche constituency of homeless women with mental illness. Within a year of starting Adaikalam that was initially envisioned as a long-term safe space for 30 women, we had already reached out to over 70. As women recovered, their expressed needs of journeying back to their families emerged and reintegration as a methodical process of enabling women to trace back their roots, with even minimal details of their origins such as the name of a village, was instituted. The experience of successful family reintegration led to the realization that multidimensional poverty and lack of localized care rather than abandonment were implicated in homelessness. Continuity of care emerged as a priority.

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From 1996 onwards, The Banyan expanded capacity by constructing new premises and began to offer multiple aftercare options for those who had left the shelter. In response to diverse pathways out of the facility sought by clients, reintegration expanded options for self-discharge, employment, living in group homes and referrals to non-mental health institutions. Multidisciplinary care, with departments, clinical processes and referral systems, was strengthened. This included critical time interventions, medical care, psychiatric reviews, psychological and social interventions such as the use of therapeutic community approach, case management, access to work and social engagement options, and comprehensive discharge planning leading to reintegration with families/communities of choice and continued aftercare. Quality systems within institutional care to focus on micro-level details such as the privacy and dignity in bathing process, availability of minimum assets such as brush, fitted coordinated clothes and so on were introduced. We also initiated service user audits, access to an external human rights committee and therapeutic community meetings. Several service users became part of the organization’s workforce, and user-led initiatives such as support group meetings and peer counselling or social enterprises were encouraged. Adaikalam or the Transit Care Centre, now called the Emergency Care and Recovery Centre (ECRC), operates as a tertiary care facility that assists homeless women with mental illness in achieving their desired social recovery outcomes by offering multidisciplinary interventions that are personalized and collaboratively planned. The ECRC has reached out to over 2000 homeless women with mental illness over twenty-five years. In the ECRC approach, particular attention is paid to discharge planning and aftercare for service users. Women access a pre-discharge recovery hub to help them acquire personal and interpersonal resources, gain independence in daily living, manage health needs, plan for work and income, reconnect with social roles and acquire strategies to navigate family and community dynamics. During and after discharge, families are engaged to help them acquire supportive strategies that can help women sustain their recovery. Every woman discharged is assigned a bespoke continued care package that is based on a graded system of five levels, with each level requiring a different combination of a range of services such as home visits, phonebased follow-up, social care across housing/education/work and cash transfers. This pre-post-discharge delivery of care is critical to the ECRC model to integrate divergent expectations of families and service users and mitigate some of the effects of multifactorial social disadvantage. Between 2004 and 2015, in response to the needs of a growing number of longstay clients at the ECRC, we developed inclusive living options that support the socio-economic and sociopolitical participation of users with low to high levels of disability. These include Clustered Group Homes (CGH) (a row of group homes co-located with our sister academic concern, The Banyan Academy of Leadership in Mental Health) and Home Again (rented accommodations in the community shared by 4–5 people with graded levels of support offered by a personal assistant). In Home Again, the emphasis is on personal recovery wherein users are uniquely supported through a personalized process of achieving well-being. The programme seeks to foster interdependence and symbiotic relationships, and thus uses social mixing and

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community participation as a means to achieve inclusion. Housing is offered as an open nonlinear option with options and choice of where they want to live that are not time-bound and open for negotiation or exit at any point in time including pathways back to institutional care if a person so desires. The focus is on lived experiences and self-evaluated personal well-being, wherein health is one among priorities for living well and not the sole focus of supportive services offered. About 200 people access inclusive living options to experience the lives they desire. By 2012, with a more nuanced understanding of the complex causation pathways that led to homelessness among people with mental illness which went beyond lack of localized access to care, we consolidated our community mental health projects in urban and rural geographies under NALAM, a well-being-oriented approach, combining early identification and clinical care with broader community engagement and socio-economic welfare interventions, delivered through a network of grass-roots mobilizers, outpatient clinics and community-based activities. About 10,000 people have benefitted from NALAM since the start of our first outpatient clinic in 2003. The Shelter for homeless men with psychosocial needs was collaboratively set up with the Corporation of Chennai as an alternative, user-initiated service contact option that offered in a smaller facility of 30 beds integrated mental health and social care within an inclusive ambience that included after-school academic support, livelihood training, a balwadi (creche) for the broader community. About 270 men have accessed the services of The Shelter. Work participation and engagement constitute a critical part of services across all projects and range from opportunity to earn incentive making a product in-house, employment in kitchen, security, housekeeping, data entry, reception and hospitality, or in external factories, homes, offices, beauty parlours and user-owned microbusinesses such as a petty shop, a laundry unit and so on. The varied options consolidated under a unified Skills Development and Social Enterprise wing. About 40% of people who are in our care are employed, either internally or externally. During the course of The Banyan’s journey, some women have arrived at our facility along with their children or have later reunited as single parents. Through NALAM and Home Again, Children living with parental mental illness (CPLMI) are offered group-based psychosocial competence workshops, mentorship and academic support. The Banyan’s evolution from a shelter to a comprehensive mental health system that spans services across the lifespan, from prevention to crisis intervention, has been in response to better articulation and understanding of needs of service users who are doubly disadvantaged with mental illness and homelessness. Given the current scenario of mental health in India, with deficits in availability, accessibility and appropriateness on the one hand, and unprecedented opportunities to fill these given the newly enacted acts in mental health and disability, what are the implications and prospects emerging from The Banyan’s experience? How can these be translated into a larger agenda for mental health policy and practice so that we can move towards newer socio-economic realities for homeless people with mental illness? To answer these questions, we present data of homeless women with mental illness who were offered care at The Banyan Emergency Care and Recovery Centre between

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2014 and 2017 (up to September 2017) maintained by The Banyan’s Monitoring and Evaluation Systems. Reintegration of homeless women with mental illness and the extent of continued care have been examined as outcomes.

Reintegration and Aftercare Outcomes of the Emergency Care and Recovery Centre (ECRC) Between 2014 and 2017, 203 women who were homeless entered the Emergency Care and Recovery Centre (ECRC), of whom 196 were diagnosed with a mental illness (Table 12.1). Table 12.1 describes the background characteristics as available at the time of admission. The mean age of women rescued by The Banyan during this period was 40.5 (SD = 9.94), with over half of them from Tamil Nadu (59.11%) followed by Andhra Pradesh (8.37%) and Bihar (7.39%). Psychosis not otherwise specified (37.44%) and schizophrenia (29.06%) were the most common diagnoses. The diagnosis was determined over the course of stay. Lack of food and adequate water intake during period of being homeless may cause altered mental health status temporarily. Five women were found to have no psychiatric symptoms during their stay—two discharged themselves, one was assisted in tracing family, one was assisted to find another institutional facility, and one of them chose to continue living with us. More than half the population (52.2%) additionally had physical health conditions that required attention: anaemia, skin lesions and infected wounds, tuberculosis, cancer, dyslipidemia and hypothyroidism. In most cases, more than one condition was diagnosed. Anaemia was the most common diagnosis (40.9%). Five women were HIV positive at time of admission. Systematic data on history of homelessness and critical incidents is not available for the entire sample. However, a survey conducted for a study of factors associated with homelessness among women accessing our outpatient clinics revealed that over 32% of them had experienced homelessness, and the odds of homelessness among women with mental illness increased with low educational attainment and relational disruptions (breaking of a steady relationship, separation due to marital difficulties and abandonment). Early analysis of data from a qualitative study (currently in progress) at The Banyan to understand narratives of illness and recovery among homeless women with mental illness presents four themes that accompany pathways to illness and homelessness—pervasive experience of sexual violence, familial violence (predominantly by intimate partners), bereavement and structural barriers: When I was young, a person raped me before marriage. I was probably seven or eight years old during that time. He was from my village. I used to think of him as an older brother. I did not even know what was happening to me. That is why there were so many problems in my family after marriage. I was unable to have sex with my husband—A In our childhood, we used to suffer a lot. (our house was) around 200-300 sq ft, one common room and all of us would sleep together. There was no bathroom. We used to go to a

180 Table 12.1 Background characteristics of women admitted to emergency care and recovery centre (ECRC), The Banyan, 2014–2017 (n = 203)

L. Narasimhan et al.

Age Diagnosis Psychosis NOS Schizophrenia Bipolar disorder Intellectual disability Others No psychiatric symptoms Alcohol use disorder Not yet diagnosed Concurrent physical health Conditions Yes No Marital status Married Single Unknown Widowed Separated Divorced Religion Hindu Muslim Christian Unknown State of origin Tamil Nadu Andhra Pradesh Bihar Others Unknown Primary language spoken Tamil Hindi Telugu Others

M

SD

N 40.5

% 9.94

76 59 31 21 7 5 2 2

37.44 29.06 15.27 10.34 3.45 2.46 0.99 0.99

106 97

52.22 47.78

103 30 28 22 18 2

50.74 14.78 13.79 10.84 8.87 0.99

165 17 15 6

81.28 8.37 7.39 2.96

120 17 15 45 6

59.11 8.37 7.39 22.17 2.96

120 43 20 18

59.11 21.18 9.85 8.87 (continued)

Table 12.1 (continued)

M Unknown

SD 2

0.99

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forest….One of my brothers used to have sex with me and spoke very badly about me to my fiancé, this spilt my life completely—G My father used to hit her very badly. Almost everyday he’ll break her hands and legs and send her to the hospital. He used to drink and come home. If my mother did not cook food he’d beat her. She attempted suicide once and we spent one month in the hospital—K’s carer She has witnessed some wrong things…in the company she used to work in. They threatened by saying that they will murder her, and that if someone told her family members, they wouldn’t care. Man and woman she saw together. They threatened to kill her…She used to say that they’ve come to kill her, they’ve got a knife, ask me to save her. This happened when my father was still alive….My father also went to several hospital and then passed away. When my father passed away, she did not cry or show any emotion. She was just sitting there—D’s carer, describing an incident wherein the client witnessed non-consensual sexual contact Three-four years back, someone cheated me out of my money. My sister’s husband… He cheated me… One lakh rupees. Yes, after my husband passed away … And if I speak about it, the middle part of my head really hurts. Because they threw so many stones at me. Like a mad lady, they were throwing all the stones at me. Please don’t tell X that they raped me; she will feel very bad—P I wandered, and two people on the streets said they would give me food and then they misbehaved with me. This has happened a lot of times with me. Once I conceived and had to have an abortion done—L

Reintegration Table 12.2 summarizes admissions and discharges between 2014 and 2017. Over three-fourths (75.35%) were discharged during the same period, with a majority returning to family or independent living through self-discharge (60.6%); 15.76% of women who required long-term care options were referred mostly to other institutional facilities followed by The Banyan’s inclusive living options for long-term care. Table 12.2 Admissions and discharges from the emergency care and recovery centre (ECRC) 2014–2017 n = 203 N

%

Admissions

203

100.00

Discharges

155

76.35

Reunited with family

117

57.64

Referred to other institutional facilities Referred to The Banyan’s clustered group homes facility for long-term care Referred to The Banyan’s home again for long-term care Self-discharge

18

8.87

4

1.97

10

4.93

6

2.96

Deaths

1

0.49

Left on their own account

9

4.43

Continue living at ECRC

38

18.72

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Table 12.3 Clients reintegrated from ECRC and length of stay by year of admission Year of admission

Admissions N

Reintegrated % (N)

Length of stay (in days)

Year 1

Year 2

Year 3

Year 4

Mdn (IQR)

2014

39

20.51 (8)

30.77 (12)

12.82 (5)

2.56 (1)

396 (419)

2015

62

24.19 (15)

35.48 (22)

8.06 (5)

0

303.5 (409)

2016

67

34.33 (23)

19.40 (13)

0

0

252 (289)

2017

35

54.29 (19)

0

0

0

77 (61)

Our Clustered Group Homes (CGH) facility had run short of space to accommodate more people, and in 2014 with the initiation of Home Again, women who required continued care with high to moderate levels of support were referred to this service located in urban and rural neighbourhoods. Of 38 women who continued living at the ECRC, 19 of them had lived with the institution for over 1 year, indicating the need for long-term care options. Therefore, the proportion of women from the 2014 to 2017 cohort with long-term care needs is 27% (55). Only one death due to natural causes and age was reported, nine women walked out of the ECRC facility, and their whereabouts and current status are unknown. A year-on-year examination of reintegrations reveals that rate of reintegration has improved since 2014 (Table 12.3). While in 2014 only 20.51% reintegrated back to the family within the first year of their admission to ECRC, by 2017 54.29% of women, who sought admission, recovered and reunited with their families. Overall, we also see a declining trend in average number of days women stay at the ECRC before making the journey back to their homes. Several factors could have potentially contributed to this improved reintegration rate as well as lower average length of stays. There were minimal incremental changes to ECRC’s ethos of care and processes based on user audits. These included quality enhancements and protocol development across phases of care ranging from psychological to social care interventions such as livelihood facilitation, legal aid, assertiveness training and confidence building to be able to assume valued social roles. However, the size of the facility changed from 171 average occupancies in 2014–100 in 2017. More significantly, the proportion of women with one or more year stays in the total population reduced over time from 80% in 2014 to 19% in 2017. Reintegration experiences among homeless men with mental illness who are serviced through The Shelter run in collaboration with the Corporation of Chennai vary from that of women who access the ECRC. Only about 32% of men returned back to their families, while 33% walked out of The Shelter. While these trends indicate diversity in experiences between men and women with psychosocial disabilities who face homelessness, these variations may not necessarily be attributable to gender alone, as the nature of ECRC, which also offers supported admissions and The Shelter, which is a walk-in and walkout facility, is different.

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Aftercare Coverage Of those discharged, 141 returned to living arrangements outside of The Banyan’s residential options (ECRC, CGH and Home Again) either to their family, living independently or in other institutional facilities (Table 12.4). Five women have returned to ECRC as the families were unable to care for them. Four women went missing from the family or institutional facility, and there were three deaths including one by suicide; 57.45% of women continue to receive ongoing care through our aftercare services through either outpatient clinics, postal medication or care partners in the country. Excluding readmissions, women missing from home, those who do not need medication, deaths and readmissions who fall beyond the purview of these services or cannot receive them anymore, the effective aftercare coverage is 65.85% (81 out of a total 123 women). An equal number of people receive continued care services at outpatient clinics which includes clinical reviews, case management, social care (disability allowance and securing state entitlements) and home visits, and through postal medication, which includes delivery of medication every quarter based on yearly reviews and phone-based follow-up. Only a minority (7.8%) have been referred to local services as paucity of local mental health services that can offer post-discharge care, to minimize risks of re-hospitalization or homelessness continues to be a challenge—seven continue treatment at local civil society organizations, three access government mental hospitals, and one prefers a private facility. Despite enrolment into an aftercare service with a plan for continued care at the time of discharge, we have lost contact with 46 women, more than a quarter, who have exited ECRC. Thirty-one of such women are from Tamil Nadu. Systematic data on reasons for service disengagement is unknown. Feeling better, migration and switching to another service provider are the most common reasons that emerge from a routine examination of dropout from outpatient clinics of The Banyan. Ceasing treatment when people feel better without waiting for clinicians to titrate or step down as per protocol is often observed in many chronic diseases such as diabetes and Table 12.4 Current aftercare status of clients discharged to families/facilities outside

N

%

In aftercare

81

57.45

Postal medication

33

23.40

Outpatient services

37

26.24

Aftercare network partner

11

7.80

No contact

42

29.79

No medication needed

6

4.26

Missing

4

2.84

Deaths

3

2.13

Readmission

5

3.55

The Banyan, 2014–2017 (n = 141)

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asthma (Bosley et al. 1995). Similarly, discordance between user–carer expectations for recovery and gains they experience precludes a tendency to seek other avenues that they hope will result in more meaningful outcomes (Shepherd et al. 2008). Overall, ECRC as a multidisciplinary intervention beginning from critical time interventions, and clinical and social care at the facility leading up to exit pathways of choice has been successful in assisting over three-fourths of those who receive such services to return to their family or to live in the community independently. Further, a prospective study of outcomes among women with long-term care needs enrolled in the Home Again intervention involving housing with supportive services reveals a significant effect of such an intervention when compared to as usual care in institutional settings with increased community integration (participation in home, at work and in the community) and reduced disability. Globally, housing interventions for homeless people with mental illness have demonstrated reduced days on the streets as an outcome. The experiences of The Banyan in implementing personalized services to support homeless women with mental illness with diverse needs, symptom status and disability levels are unique in its impact on social recovery outcomes such as return to work, pursuing lived experiences with personal meaning social roles and social inclusion. Given the inherent inclusive nature of living and gains for quality of life for those with low to high disability, these approaches are feasible options to adopt for people who may need these to prevent long-term institutionalization and stays beyond a year in tertiary facilities. Aftercare in this continuum of care operating within constraints of limited localized services has continued to engage with two-thirds of women returning home to assist them in sustaining recovery and preventing recurrent hospitalization or episodes of homelessness.

Lessons and Implications for the Mental Health Sector Address Crisis of People with Long-Term Care Needs Despite all efforts that The Banyan undertakes to reintegrate people back to families or enable them to live independently, there remains a cohort that requires long-term service support. In 80% of these cases, we have been unable to reunite women because of lack of information for two reasons: half of such women have high disability, while others do not wish to return to environments where they have experienced violence. In a minority of cases, families, which already face deprivations, are ill-equipped to care for people with mental illness especially if they are not actively contributing to the household income or are visibly deviating from normative expectations of appearance and behaviour in the neighbourhood. Institutional mental health facilities across the country are looming under this invisible crisis of people incarcerated for long years, a significant proportion of whom are women. The right of people with mental illness to live lives of their choosing as any other citizen in a democratic nation is severely compromised by extending their stays in closed facilities beyond the acute phase of

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illness. In February 2017, the Supreme Court of India issued an order directing the centre to develop a policy for long-stay service users in mental hospitals in response to a petition that highlighted the issue. Mixed experiences of de-institutionalization in the Western nations during the 1970s (Thornicroft and Tansella 2002) ought to serve as a warning for us to not adopt a rapid discharge policy in haste without commensurate pace of community care expansion. Our experiences with Home Again, studied prospectively with an as usual care group receiving institutional care, demonstrate that with adequate and appropriate supports and emphasis on a high quality of life for people with mental illness, even those with high disability encounter gains, return to social roles and participate in the socio-economic fabric of communities. Against the history of pervasive gender-based violence and failure of clinical therapeutics, through Home Again women have been able to form atypical familial arrangements with peers and assert their right to live in the community. We recommend the development of a carefully thought-out policy that draws out individualized rehousing options, whether through reintegration with family, housing with supportive services or independent living with employment, while parallelly investing in supportive community care resources. Comparison of limited background characteristics available at the time of admission between those who return home successfully and those who continue long term does not reveal any significant differences. However, this may be because the differences lie in household or neighbourhood characteristics, carer attributes and more thorough data on history and trajectories of mental illness and homelessness. Research to uncover reasons for these diverging realities among homeless people with mental illness may assist in better planning and service provision including mitigating risks for long-term disability.

Large-Scale Institutional Mental Health Transformation State mental health facilities need to be extricated from the vestiges of the colonial era and refreshed in their social architecture that includes ethos, systems and processes of care, and not merely in infrastructure or academic and research capacities. Due to power imbalances being tipped unfavourably towards people with mental illness, Maj (2011) extrapolates on the need for rights-fostered care provision, without which delayed remission, stagnant symptomatology and amotivation become realities. Spatial reorganization and infrastructure investments must directly impinge on service user’s opportunities to pursue recovery, in such a way that liberation of self is possible without constraining the needs that may present because of the illness. The potential consequence of such ‘built environments’ is mirrored by Evans (2003) who prospectively links social ecologies to better psychosocial outcomes. In The Banyan’s experience, in a bid to do more the institutional facility grew too large and disproportionately with long-stay users. Rationalizing ECRC’s bed strength and incrementally enhancing institutional capacities to be user-centred and accountable has contributed to better quality care and faster recovery and return to

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families for homeless women with mental illness. Therefore, the discourse on mental hospitals, which undoubtedly suffer from deep-rooted hegemony but can evidently support recovery if the locus of care is reoriented, needs to move away from deinstitutionalization to critical questions of what size should such hospitals be, what should be the staffing structure and most critically what will be the driving philosophical non-negotiables permeated as culture at all levels that assure service users are full participants in the process of recovery. It becomes critical to identify leadership that can drive this transformation across the country and negotiate the difficult terrains of spaces that languish in years of apathy. Such an effort has the potential for long-ranging consequences for the mental health sector in India, with improved outcomes among people with mental illness, reduced stigma and discrimination with increased personal evidence of positive recovery gains, and increased staff morale.

Early Intervention and Strengthening Support Networks As much as crisis intervention is a priority, prevention of people with mental illness lapsing into homelessness needs to be pursued. Prognostic value of early intervention in psychotic disorders is well established in the literature—length of untreated psychosis is associated with chronicity and poor outcomes (Marshall et al. 2005), while intervention at the critical early phase of onset predicts social and vocational functioning (Perkins et al. 2005). Specialized early intervention services that run in liaison with primary care such as TIPS, RAISE, OPUS and LEO have demonstrated positive gains of better functioning, reduced inpatient care use and independent living (Craig et al. 2004; Johannessen, et al. 2000; Petersen et al. 2005; Rosenheck et al. 2016). The District Mental Health Programme may be mandated with a focused early identification component, especially among vulnerable populations followed by intensive specialist team engagement with identified individuals in community care settings for a 2–5 year period followed by transfer to maintenance teams and appropriate escalation in the event of loss of gains. Similarly, people discharged from tertiary care/inpatient settings, those with a history of homelessness and those running a chronic course with unremitting symptoms or absolute poverty, require specific attention and consistent engagement to support their living in the community and reduce the use of inpatient resources.

Community Mental Health with a Gender-Responsive Development Agenda If identification and provision of care are essential, as are efforts to make sure that women do not spiral down the trapdoor of homelessness or illness. Interconnecting clinical pathways to grass-roots mechanisms such as routine engagement by

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a community-based mobilizer leads to development of social protective networks that may mitigate some of the risks. Van Ginneken et al. (2014) discuss on how latitudinal diffusion of resource-intensive operations to more catchment areas, alongside reorientations of primary caregivers, can aid in walking away from ‘biomedical models’ to ‘a process of thinking’ needed for lengthened well-being. Stakeholder engagement that connects beyond the user-carer combine is essential. These engagements may be with members of general public, postal staff, auto drivers, village health nurses, neighbours, balwadi (creche) teachers and anyone who will be able to further linkages of care. A study by Glanz et al. (2008) documents the direct effects and the buffering effects of such exercises in social relationships as they help in ‘managing uncertainty’ and ‘validating emotions’. Causation pathways for homelessness among those with mental health issues are multivariate and occur more often than not when a combination of social deprivation and disadvantage persists alongside mental illness. Seng et al. (2012) suggest that lack of access due to intersectionality may impinge upon users’ lives to such an extent as to push them into a state of ‘double jeopardy’. Padgett et al. (2006) point to the loss of ontological security and exhaustion of all social resources as a defining feature of homelessness experienced by women with mental health issues. Social factors such as hunger, violence and discrimination lead to enduring social liabilities. Health systems that seek out those at risk but offer only biomedical solutions, neglecting the individual illness narratives of social disadvantage and heightened vulnerabilities, may not be sufficient to prevent or address homelessness among people with mental illness. In our particular experience with women, gender-based violence and disempowered status emerge as risk factors. While localized access to early treatment is a critical goal, it is relevant to note that a majority of them had sought treatment earlier and yet had been rendered homeless. Services may mirror therapeutic relationships that are extensions of the hegemonic patriarchal structure and therefore either ignore, dismiss or pathologize women’s experiences. A more decisive end to homelessness among women with mental illness may require reductive conceptualizations based on paternalistic imperatives to be replaced with a sincere acknowledgement and redressal of structural factors that perpetrate gender inequalities and relegate them to the margins. Removing structural violence which is a significant contributor to both mental ill health and homelessness must form a part of public health priority through intersectoral advocacy, mutual agreements and collaborative delivery with social sector department even if the health system does not directly implement such measures. Similarly, families and communities are located within the larger sociopolitical and sociocultural framework that continues to prejudicially treat women. Notions of recovery restrained by gender role expectations in such a context may perpetuate the illness and lead to recurrent homelessness. In our experience, strategies such as assistance in the form of gender-based counselling, reformulating illness and recovery conceptualizations and incrementally enhancing roles played within family and community have helped. Erosion of resources leading to homelessness in the face

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of loss of dependency relationships may be mitigated by reconstructing pathways to social and economic independence through supported employment or social cooperatives.

Rethinking Human Resource Structure The Banyan’s services are primarily delivered by a trained and supervised lay cadre or a non-specialist workforce who are themselves drawn from difficult socio-economic circumstances. Over years, experiential experts, service users and carers have come to occupy many of these roles as peer advocates in the system. There is increasing evidence from across the world that a wide variety of interventions may be successfully delivered with high fidelity by appropriately trained and supervised lay workers who do not necessarily possess professional qualifications in mental health (van Ginneken et al. 2014). The ‘feasibility of such local partnerships’ and ‘task-sharing models’ can help in bringing in ease in service delivery and reduce workload burden as well as address key logistical challenges that may crop up with a one-sided dependence on specialists (Mendenhall et al. 2014). Further, for services to take cognisance of social determinants of mental health and conscientiously deliver interventions to address these, roles of various disciplines other than psychiatry such as social work within the mental health system need to be invigorated to depart from a fallacious and often default physician assistant roles to that of specialists who offer inputs derived from their disciplines. Establishing cross-sectoral linkages with existing cadre of poverty alleviation and disability programmes to offer mental health care may be necessary to quickly increase availability of staffing for upscaling of services. Addition of negotiator roles at the grass-roots level in both institutional and community settings to assist people in navigating care resources, both clinical and social, may become pertinent for achieving gains on the social justice front. Effective mental health delivery also requires cultivating leadership and management among human resources so that staff can sustain quality and fidelity to original goals and adapt and innovate services in response to changing realities and new emerging needs.

Conclusion As a nation, our collective goal of economic and social prosperity can never be met until we remain oblivious to the peripheral existence of homeless women with mental illness. Gender-based disadvantage is implicated in homelessness in the background of mental illness among women. Both qualitative narratives of women that The Banyan has worked with over the several years and quantitative evaluations indicate experience of persistent gendered violence over the life course and how these shaped the trajectory into homelessness, and not merely the absence of early treatment per se for mental illness. In such a context, mental health care limited to biomedical

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formulations of women’s presenting distress and broader context of social deprivation curtails the quality and appropriateness of care women are offered. Based on The Banyan’s experience, it would be essential to shift the narrative of psychiatric services towards formulations that are cognisant of women’s experiences and offer the necessary integrated supports that may range from housing, (re)-establishing new social roles, to work participation and employment that move beyond patriarchal norms. Gender-responsive restructuring of mental health services with an unyielding focus on justice may be an essential step to establish an egalitarian ecology that presents opportunities for the most marginalized groups to thrive.

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Chapter 13

Tarasha’s Experience of Working with Women Living with Mental Illness: ‘Melee tar aamchi, Jagli tar tumchi’(‘if she dies she is ours, if she lives, she is yours’) Shubhada Maitra and Ashwini Survase

Introduction Pooja. Age 32 years. Works in the retail and sales department of a flagship store in a mall in Mumbai. Earns a monthly salary of Rs. 10,000. Speaks fluent English, Hindi and Marathi and currently stays in a working women’s hostel. Pooja first came in contact with Tarasha in 2011, when we initiated our work with women with chronic mental illness in the Regional Mental Hospital, Thane. She was admitted to the hospital by her aunt in December 2008 with complaints of abusive and aggressive behaviour, muttering to self, picking fights with people unnecessarily, roaming around the streets of Mumbai at odd hours, tearing her clothes and so on. On admission, she received a diagnosis of Schizophrenia which is marked by a complete disorganization of personality, disturbances in thoughts, feelings, behaviour, hallucinations and delusions, loss of orientation to reality and so on. The person becomes almost unrecognizable to near and dear ones due the drastic changes in behaviours and social interactions. The same thing happened in Pooja’s case. Having spent three years in the hospital, Pooja was now free from the symptoms of Schizophrenia. She was communicative and was eager to get out of the hospital, but her elderly father was in an old-age home by then, and there was no one to look after Pooja. Tarasha connected with Pooja in the hospital and began to work with her and several other S. Maitra (B) School of Social Work, Tata Institute of Social Sciences, Mumbai, India e-mail: [email protected] A. Survase Tarasha, Tata Institute of Social Sciences, Mumbai, India © Springer Nature Singapore Pte Ltd. 2020 M. Anand (ed.), Gender and Mental Health, https://doi.org/10.1007/978-981-15-5393-6_13

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women with the objective of getting them to start a new life outside of the institution afresh. This paper discusses Tarasha’s experience of working with women living with mental illness. While tracing Tarasha’s conceptualization and history, it outlines Tarasha’s recovery and reintegration model drawing on real-life experiences of women who are currently ‘occupying’ mainstream living and livelihoods spaces. Tarasha is a community-based field action project of the Tata Institute of Social Sciences, established in 2011. The main objectives were to address women’s mental health issues and hitherto unmet needs to facilitate recovery and reintegration. Safe shelters, psychosocial care and livelihoods are the three cornerstones of Tarasha.

The Inspiration Tarasha was conceptualised based on a research study conducted by the first author in 2002–2003, titled Status of Women in Mental Hospitals in Maharashtra commissioned by the Maharashtra State Commission for Women (Maitra 2003). The study covered all four regional mental hospitals located in Thane, Pune, Nagpur and Ratnagiri in Maharashtra and utilized a mixed methodology approach to understand women’s mental health issues. Quantitative data collection was undertaken by perusing case records to obtain a profile of women suffering from mental illness. A total of 1949 case records of women residents of the four hospitals at the time of data collection were studied with a focus on women’s socio-demographic details, illness and hospitalization history, gynaecological and physical health problems, and psychiatric profile including treatment, discharge and rehabilitation. In addition, indepth interviews (IDIs) with 10 women and three focus group discussions (FGDs) covering 25 women were undertaken. Women participating in in-depth interviews, and focus group discussions were asymptomatic at the time of data collection. IDIs captured women’s life experiences with a focus on events prior to the onset of illness, factors resulting in distress and trauma, hospitalization, stigma and discrimination and violence and abuse. The FGDs explored women’s psychosocial, occupational and illness history, their understanding of the illness, hospitalization, recovery, rehabilitation, current needs and aspirations for the future. The women were identified with the help of hospital social workers and superintendents. Key informant interviews with stakeholders in each hospital were also undertaken to explore how women’s treatment, care and rehabilitation issues are perceived and handled within the hospital setting. Consent was sought from all participants and confidentiality and anonymity assured. Some key findings from the research were indeed disappointing and disturbing. Women were typically admitted to the hospital in their late 20 s and early 30 s. Yet, women’s age at the time of data collection was on an average 7–10 years more than the age at admission. This meant that women were growing older in the institution and had lost their most productive years to hospitalization. Similarly, nearly 70% women were admitted to the hospital by their family. Yet, only 29% women ever

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went home on leave of absence. The question that puzzled us was: why did the women not get leave of absence? On enquiring with key informants, it was revealed that the families abandoned the women in the hospital following admission. They changed their homes, locked the house and disappeared if they knew the woman was being sent back home or refused to take the woman in. A superintendent of one of the hospitals narrated her experience of how women are abandoned in the hospital: A man had come with his 20–22 year-old daughter for admission to the hospital. The daughter had complaints similar to mental illness, was single and pregnant at the time of admission. On completing the formalities of admission, the father said to the Superintendent, ‘Melee tar aamchi, Jagli tar tumchi’ (‘If she dies she is ours, if she lives, she is yours’) (Maitra 2003). The quote eloquently describes the stigma attached to being a woman, mentally ill, single and pregnant! Key informants across all hospitals shared such experiences and emphasised that the same was not true for men who were granted leave of absence. Families often looked forward to the man’s return as most times he is considered a potential wage earning member of the family, a head of the household, husband to his wife and father to his children. These roles are irreplaceable. But the same was not true for women. They could be easily discarded and replaced. More importantly, while families abandoned the woman easily, women continued to care for their husband and rarely left him despite his mental illness. Another important finding was related to women’s aspirations. While they had spent their important years of life in the hospital, had very little formal education, they expressed a desire to stand on their own feet and fend for themselves. Tarasha was established almost a decade later to realize some of women’s dreams for a life outside the institution.

The Beginnings In 2011, I was introduced to a philanthropist who wished to donate his life savings to mental health. His initial idea was to start a half-way home. On discussion, we agreed that creating another institution which will continue to house chronic patients was not the best way to meet women’s needs and aspirations. I had discussed my research findings with him. In our first meeting, he agreed to donate a substantial amount to mental health interventions with women. And that is how Tarasha took shape. Our idea was to work with women who had no family support and were abandoned by their families in the hospital due to their mental illness. Although asymptomatic, women had nowhere to go and with very little skills or formal education, would be unable to fend for themselves in the open world. We thus decided to link psychosocial care, shelters and livelihoods towards recovery and reintegration. Our first collaboration was with the Directorate of Health Services (DHS), Maharashtra. Given that women who wished to work with were asymptomatic adult women, we decided to operationalise the social work principle of ‘client selfdetermination’ and UNCRPD principle of ‘legal capacity’ (CRPD, Article 12, pg10) to seek women’s discharge from the mental hospital. We approached the DHS with

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our proposal. Initially, there was some hesitation to reaching the agreement about women’s discharge, particularly when there was no legal guardian. We argued that adult women, albeit with a history of mental illness but currently in remission did not need a legal guardian. However, the issue of readmission in the event of a relapse needed to be considered as admissions to the mental hospital follow a judicial process. We were also urged to assume guardianship for women by seeking leave of absence instead of a discharge. However, given our feminist critique of the family as an institution, we were reluctant to assume the guardian’s role. When we persisted, the then Director DHS agreed to facilitate women’s appearance before the Visitor’s Committee and if found fit to be discharged, to grant that too. That was our first victory. In the history of mental health interventions in India, Tarasha was the first project in 2011 which was granted the permission to get women with no family support discharged from the hospital. Over the last several years, Tarasha has been working with women living with mental illness to facilitate their recovery and reintegration. It challenges conventional notions of ‘rehabilitation’ of persons with mental illness by seeking mainstream livelihood options, mainstream living spaces for women with mental illness. There are several questions that we are often asked: Is this really possible? Can women with a long history of mental illness sustain jobs and a life outside the hospital? Can they really fend for themselves? And even if they do, for how long? What if they relapse? Given their mental condition, sometimes they may be unpredictable, what happens then? We wanted to respond to such questions convincingly and therefore needed a model that presented a different picture of those suffering from mental illness. Public images of the mentally ill are of persons who are permanently dysfunctional, disoriented and disorganised, incapable of performing any tasks in the psychosocial and economic spheres of life. The images become more pronounced and beliefs consolidated if the subject is the woman. Although the discourse around mental health issues is fast changing as a result of testimonies by famous (Bollywood) personalities, the signing of the UNCRPD (2007), the introduction of the new Mental Health Care Act in 2017 and advocacy efforts around recognition of rights of the mentally ill, ground realities are still far away from the rhetoric. This is particularly true for women living with mental illness.

Women’s Lived Experiences Our work with the women in the hospital helped us understand their lived realities, the socio-cultural and environmental factors that drove them to madness and their current needs and aspirations. Some of the case studies of the women we have worked with are outlined below.

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Seema Seema was admitted at the age of 22 years to the Regional Mental Hospital by the police in 2010. One of her uncles had brought her to Mumbai from Bihar on the false pretext of getting her a job. Seema was the only daughter of her parents. She lost her father in early childhood, and by 10–11 years of age, she lost her mother too. She has no memories of her father but remembers working on the brick kilns with her mother. The living conditions were difficult, as they were subsisting on the daily wages, they earned from making bricks. Seema was close to her mother and after her death remembers feeling extremely alone and unsupported. She could not sleep well at night and when she did dreamt of her mother. Soon, she began hearing her mother’s voice. Seema’s neighbours looked after her till the age of 16, but got her married off much against her will. In two years, Seema was mother to a baby boy. Her relationship with her husband was strained as he would abuse her emotionally and sexually. When she could not tolerate it any more, she returned to her village with her young son. Her in-laws did not like this, followed her to the village and forcibly took away her son. Seema was helpless and distressed. Around the same time, one of her uncles promised to get a job in Mumbai and sold her to a brothel keeper. Although she escaped from there a few days later, she was distraught by this time. Alone in a big city with no known contacts, she says she ‘lost her mind’. She often saw her dead mother and chatted with her. The police found her in this state and brought her to the hospital where she received a diagnosis of Schizophrenia.

Neha Tall, confident with an attractive personality, Neha first came in contact with Tarasha in Ward 19 of the hospital. Like Seema, she too was admitted to the hospital by the police. She was diagnosed with Brief Reactive Schizophrenia, a condition that has a sudden onset and is of a brief duration. Neha came from a well-to-do family, had completed two years of B.Com. Degree, but reached this mental state when she was swamped by one dreadful experience after another. She grew up in Sanganer, Jaipur. Her parents were highly qualified and had an inter-caste marriage. Both families were opposed to the marriage; as such Neha’s parents did not have much contact with their respective families. Neha had an elder sister who married a man from another religion. Her parents thus expected Neha to marry a boy of their own choice, from the same caste group. In the second year of college, her parents abruptly stopped her education and forced her into marriage. She made truce with her reality and began living with her husband, in-laws and two brothers-in-laws. Her husband was also well-to-do and worked with the family business. Neha had very little knowledge about his work. By her own admission, Neha asserted, ‘I loved

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my husband dearly, we had a nice life. My brothers-in-law too were nice to me. Yes, I did have small differences with my mother-in-law, but my father-in-law always supported me’. Neha gave birth to two children two years apart. Soon she lost her father-inlaw. A few years later, her husband too died an untimely death. Between 2002 and 2006, her life turned upside down in a span of four years. Soon her mother-in-law began insisting that Neha marry her younger brother-in-law. This was not acceptable to Neha, and one day in a fit of desperation, she left home with her children. She borrowed money from her elder sister and admitted her children to a Boarding School. She reached Mumbai to earn a living and ended up in a dance bar. She accepted that situation too and kept telling herself that she is doing this for her children. However, her work was very stressful. She decided to end her life by consumed sleeping pills and went for an autorickshaw ride around the city. When she woke up, she found herself in the mental hospital.

Maya Maya was admitted to the hospital at age 24 by her uncle in 2004. Family history of mental illness was recorded by the uncle at the time of admission. Maya’s elder brother is mentally challenged, and two younger sisters are also living with mental illness. All the siblings were being looked after by their uncle and aunt. Maya has no memory of when or the conditions under which she was admitted to the hospital. Her mother’s death was a big blow to Maya. She took treatment from a private practitioner for depression for a few years. Maya describes herself as a loner, but loved dancing and singing. Her talents gave her an opportunity to participate in the cultural programmes organised by the hospital from time to time. Ever since her admission in 2004, till 2011, Maya had never gone home on leave of absence. Her uncle and aunt were growing older and were not in a position to support Maya any longer. These are typical examples of women we come across in the hospital through Tarasha. While Maya’s condition was hereditary, many others like Seema and Neha are a victim of oppressive social circumstances. Years of living inside the institution results in a complete cut-off from the outside world. Families are lost, and women find themselves alone in the hospital with no hope of ever getting out. Tarasha came in contact with these and several other women in the hospital when we began work in 2011. Although they were on the path of recovery, their future was bleak. We began work with women who were asymptomatic.

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Tarasha’s Model of Intervention The sub-section below outlines Tarasha’s phases through which women move towards recovery and reintegration (Maitra 2019).

Phase I: Towards De-institutionalization This is a stage of screening, selection, capacity building and a move towards deinstitutionalization. Women are selected with support from hospital staff on the basis of their eligibility and interest to join Tarasha and start a life outside the hospital. Selection of potential participants for the project is based on degree of family/social support, level of functioning, remission of symptoms, insight, and willingness to join the project. Women who are discharged are aged between 22 and 45, keeping in mind mainstream employability opportunities.

Therapeutic group sessions in the hospital

Therapeutic group sessions on themes such as self-care and hygiene, understanding mental illness and related factors, possible reasons and stressors and typical response to stressors are scheduled 2–3 times a week, where participation is voluntary. Additionally, sessions on gender, emotions, sexuality, team work and life outside the institution are also included in this phase. The sessions take anywhere between 4 and 6 months of intensive group work. This begins the process of preparing women mentally and emotionally to step out in the open world.

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On their way out following discharge from the hospital

Phase II: Psychosocial Recovery Following discharge from the hospital, women stay in working women’s hostel. Given their loss of contact with the outside world during long-term hospitalization, they are unaware of socio-political developments in the society. Many are unfamiliar with the city, and hence, the first effort is to help them know the city, understand ways to negotiate both public and private spaces. Many of the everyday joys that seem so ‘run of the mill’ are a novelty for women who exit from an institutional set up after years of incarceration. Going to the beach, seeing homes of their favourite filmstars, taking the public transport are small pleasures in their lives. Tarasha has been able to identify several such hostels which readily house our women. Hostels provide a safe secure environment that fosters our clients’ recovery. This is also one of the first spaces wherein the clients begin to meet and interact with other women from different avenues of life, as well as other clients in later phases of the project. This is when the clients’ begin to shape an identity for themselves outside the bracket of a diagnosis, and apart from their illness. The idea of the ‘future’ starts to become more concrete. A major challenge is readjusting to a life outside the hospital, with a strict schedule, negotiating spaces and interacting with the other women present.

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While they get used to the city, the women also begin to attend a day care centre for persons recovering from mental illness. Here, they focus on the triad of thoughts, feelings and behaviours, re-learn social and interaction skills, deal with challenging situations and handle emotions effectively. This phase typically lasts 3 months and is followed by vocational training.

Tarasha women and team members enjoying a picnic together

Phase III: Vocational Training Once women complete 3 months at the day care centre and are ready for vocational training, they are placed with such institutions that offer training in specific livelihood skills. The training typically lasts about 3 months. Following successful completion of training, women appear for interviews and are selected for job placement. Besides vocational training, this phase also sees women interact with other students in a learning environment, appear for job interviews and get selected on a competitive basis. Just as opportunities open up in Phase III, it also brings several challenges. Women have to go beyond their identity of a person with mental illness to someone who is a student-learner, a potential employee, a colleague and so on. It is at such times that self-doubt and fear surface often. The women also re-learn and re-adapt their understanding of boundaries and relationships here. Distinguishing between friends and colleagues, identifying strengths that set them apart from the rest of the student-group, learning new behaviours beneficial to the workspace and absorbing what is taught during the training become important indicators for the women.

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Phase IV: Job Development and Job Support

Travelling around in Mumbai

The real test begins in this phase. Now is the time to present themselves to the world, as a productive member of society. Tarasha views hitherto conventional approaches for persons with mental illness such as candle-making, handicrafts, pickle and papad-making, stitching and packaging unviable towards a sustainable livelihood. Instead, our effort is to secure mainstream employment for women so that they can truly stand on their own feet and become economically independent. Till date, Tarasha women have worked in sectors such as hospitality, housekeeping, retail and sales, printing technology, home-based care and hospital-based patient care, earning a starting salary of Rs. 8000–10,000 per month. Women begin a formal job in this phase and establish a routine for themselves, both in the hostel and at the workplace. They forge connections and friendships which sustain them emotionally. Tarasha continues to support women through this phase by offering regular counselling sessions and helping women deal with the realities of everyday living. In addition, we are occasionally required to do troubleshooting at the workplace in the event of work-related issues. We have been receiving positive feedback about our clients and their work ethics both from vocational training institutes and employing organizations.

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Phase V: Exit This stage has been strategically instituted for the women participating in the project. This phase is to provide closure to the process the women have been a part of for the last several months as well as to represent the clients’ independence. In this process, we provide the client with a written document, quite like the one they signed upon participating in the project. The document highlights the clients’ work and accomplishment in the time they have been a part of Tarasha, acknowledging their participation, efforts and commitment to recovery. In addition, we include a maintenance plan based on our work with the client, and usually including insights that the client has provided through the counselling sessions. This document is symbolic, a tangible way for the client to acknowledge contracting with themselves, and taking up responsibility for their recovery, seeking help, and lifestyle. We constantly reiterate during this process that we are always available for psychosocial assistance, and that the client is responsible for seeking help. This stage is more than just a document. Prior to the actual ‘ritual’ associated with exit, we are in constant contact with the client, until she is ready to acknowledge her independence formally. At all points however, we stress on the fact that exit does not equal abandonment, rather the acceptance of responsibility for oneself. In case of any ‘back and forth’ noted in terms of adherence to medication, or any anomalies in behaviour, the team towards accessing medical help and providing psychosocial assistance as required (Maitra 2019). Till date, Tarasha has worked with more than 500 women in the hospital. Not all women are destitute, some even return to their family following treatment at the hospital; yet they too need the therapeutic inputs to re-enter the family and maintain recovery. Tarasha has supported approximately 7–10% of these women with no family contact to be reintegrated into mainstream society. It is also important to understand that the women Tarasha works with come from all walks of life and families that abandon women also belong to middle- and high-income groups.

Back to Lived Experiences Where are Seema, Neha and Maya today? Are they still maintaining their recovery after so many years? Following discharge from the hospital, Seema underwent training in housekeeping and began working in the housekeeping department of a big corporate organization, earning a monthly salary of Rs. 8500. A few years later she married one of her colleagues and has a one-year-old child now. Her husband knows her illness history, and both of them are in contact with Tarasha. Neha joined Tarasha in 2014. She obtained vocational training in retail and sales and is currently working as cashier in a mall in Mumbai.

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Maya was discharged in 2011 and joined Tarasha soon after. Instead of going back to her uncle and aunt, she expressed a desire to work and earn for herself. She stayed in a working women’s hostel and obtained training in housekeeping. For the last 8 years, she has been working in a big organization as housekeeping staff. Recently, she has rented a room near her uncle’s residence and lives on her own. Two years back, Maya showed signs of a relapse. She had to be readmitted to the hospital for a few months. However, with support from the hospital and Tarasha teams, she recovered soon and was once again discharged from the hospital. She has resumed her job, adheres to her medication schedule, looks after her sisters and comes for regular counselling to Tarasha.

In Conclusion Prior to coming in contact with Tarasha, the only identity of these women was ‘mad’, ‘mental’, ‘pagal’, essentially nothing beyond a ‘mad woman’. In the hospital, they would be normally identified by a file number in a particular ward. However, their association with Tarasha has provided them with multiple identities, that of a hostel mate, employee, co-worker, and most importantly, as a citizen. When they were discharged from the hospital, they did not have a shred of document to prove their identity, not a ration card, not any educational certificates, no proof of residence, nothing. After all who carries certificates with them to a mental hospital? And what happens when they lose all contact with their family? While recovery and reintegration are key goals of Tarasha, a core issue we engage with is the politics of identity. It is not only necessary for women to go beyond the ‘mad’ identity to experience themselves in different roles, but also enjoy the advantages and entitlements of being a citizen. In 2013, Tarasha was the first mental health project in the country to open bank accounts for women and get a PAN and Aadhar card (the latter when it became operational). In a true sense, the women had established their identity as citizens. Women like Pooja, Seema, Maya and Neha do not need sympathy. They need access to rights and opportunities to live a meaningful life outside the mental hospital, enjoy the everyday and mundane happenings around them, earn a livelihood, make their own decisions, live in non-segregated spaces and access psychosocial support and services when needed. Acknowledgements This paper is adapted from the Marathi version of an original article bearing the same title with permission from the Publishers.

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References UNCRPD. (2007). Convention on rights of persons with disabilities and optional protocol. United Nations. Maitra, S. (2003). Status of women in mental hospitals in Maharashtra. Mumbai: Tata Institute of Social Sciences. Unpublished Report. Maitra, S. (2019). Reconceptualising urban spaces: towards recovery and reintegration of women with mental disorders. In D. Bhugra, A. Ventriglio, J. Castaldelli-Maia, & L. McCay (Eds.), Urban mental health (pp. 322–336). Oxford: Oxford University Press.

Chapter 14

Gender Differentials in the Presentation of Symptoms, Assessment, Diagnosis and Treatment of Mentally Ill Prisoners Mark David Chong, Amy Forbes, Abraham P. Francis, and Jamie Fellows

Introduction Critical criminologists have long railed against the injustices perpetrated by entrenched socio-structural interests within societies. Whether denouncing proletariat ‘false consciousness’ engendered by capitalism or ‘MALEstream’ (a play on the word ‘MAINstream’) dominance perpetuated by the patriarchy, critical criminology has attempted to examine ‘… class, gender and race/ethnic biases and oppression in all of their ubiquitous forms’ (American Society of Criminology [ASC] Division of Critical Criminology and Social Justice n.d.). Feminism, one of the most prominent schools within this overarching criminological perspective, actively analyses the gendered nature of the criminal justice system, and in that regard, feminist scholars have broken tremendous ground that have led to, among other important improvements, the: … development of feminist theories of crime that place issues of gender at the centre of the analysis … [;] removal of the silence around crimes against women … [;] demands for law reform … [;] [and an] analysis of the treatment of women by the criminal justice system … (White and Perrone 2015, pp. 172–173).

White and Perrone caution us though that ‘… while the law purports to be neutral and impartial, its gendered nature and differential application to women and men in M. D. Chong (B) · A. Forbes · A. P. Francis College of Arts, Society and Education, James Cook University, Townsville, QLD, Australia e-mail: [email protected] A. Forbes e-mail: [email protected] A. P. Francis e-mail: [email protected] J. Fellows College of Business, Law and Governance, James Cook University, Townsville, QLD, Australia e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2020 M. Anand (ed.), Gender and Mental Health, https://doi.org/10.1007/978-981-15-5393-6_14

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practice, can produce substantive injustices’ (2015, p. 97). This chapter will continue in that same feminist criminological tradition and examine the extent to which gender plays a key role in the presentation of symptoms, assessment, diagnosis and treatment of mentally ill prisoners. From a criminal justice perspective, the importance of such an analytical examination is amply clear. The ‘Standard Minimum Rules for the Treatment of Prisoners’ that was adopted by the First United Nations Congress on the Prevention of Crime and the Treatment of Offenders in 1955 stipulated via Rule 62 that ‘[t]he medical services of the institution shall seek to detect and shall treat any… mental illnesses or defects which may hamper a prisoner’s rehabilitation’. There is therefore explicit recognition that mental illnesses and defects can impede an inmate’s rehabilitation. What is unarticulated in this rule, however, is an acknowledgement that there is a critical mediating factor between these two elements, and that is— gender. Thus, the ensuing analysis here will explore how the gender of a prisoner influences the way in which a mentally ill inmate presents their symptoms (and seeks medical assistance); as well as how they are thereafter assessed, diagnosed and treated by prison health services. By doing so, it is hoped that penal administrators and correctional health professionals in India will be made more aware of, or sensitive to, these variances, and that the subsequent assessment, diagnosis and treatment of such prisoners will be more gender-responsive so as to maximize the prospect of successful rehabilitation. To that end, this chapter will outline key gender-relevant features of the Indian Penal System (including the prevalence, or otherwise, of mental illness among its inmates); how mental illness can impact upon a prisoner’s prospects of being rehabilitated; how gender acts as a mediating factor between mental illness and its effective detection and treatment; why there is a need for Indian prisons to adopt a more genderresponsive approach; and finally what sort of measures should prison administrators and correctional health practitioners implement in order to more fully account for the gender differentials embedded in the presentation of symptoms, assessment, diagnosis and treatment of mentally ill prisoners in India.

Gender, Occupancy Rates, Childcare and the Indian Penal System (as at 31 December 2016) In 2016, India had a total of 1412 prisons (encompassing Sub Jails, District Jails, Central Jails, Open Jails, Special Jails, Woman Jails, Borstal School as well as Other Jails), with an incarcerated population of 433,003 inmates (National Crime Records Bureau 2019, p. xi). This represented an occupancy rate of 113.7% (i.e. ‘the number of inmates accommodated in jail against the authorized capacity of 100 inmates’), and while this was a decrease from the previous year’s occupancy rate of 114.4%, this figure nevertheless suggests that there is still a significant overcrowding issue in Indian prisons. In the context of this chapter, overcrowding is an important issue

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to take into account because of the potential ‘adverse effect [it can have] on [the] mental health’ of prison inmates (WHO 1999, p. 7). According to the National Crime Records Bureau, ‘[o]ut of the 433,003 prisoners, 414,505 were male prisoners and 18,498 were female prisoners’ (2019, p. xii). While one might assume that all of these female inmates would be housed in Woman Jails—that is not the case. Out of the 1412 prisons nation-wide, only 20 of them are Woman Jails, and these are located in merely 13 out of the 36 states and union territories in India (2019, p. xii). Such Woman Jails are usually ‘managed and run entirely by women’ (Cherukuri et al. 2009, p. 257) but as foreshadowed earlier, most female inmates are actually incarcerated in ‘Prisons other than Woman Jails’ (i.e. in women’s sections of these non-Woman Jails). In fact, only 3122 female inmates were imprisoned in Woman Jails while the remaining 15,376 were housed in other types of prisons across India (National Crime Records Bureau 2019, p. xiii). Even though these 20 Woman Jails have a collective occupancy rate of only 60.1% [as at 31st of December 2016] (National Crime Records Bureau 2019, p. xiii), the following states have nevertheless experienced significant overcrowding: (1) (2) (3) (4)

Delhi [Occupancy rate of female inmates: 138.0%]; Bihar [Occupancy rate of female inmates: 132.5%]; West Bengal [Occupancy rate of female inmates: 122.0%]; and Maharashtra [Occupancy rate of female inmates: 117.2%] (National Crime Records Bureau 2019, p. 16).

That said, it should be noted that all of these states only have one Woman Jail within their respective jurisdictions (National Crime Records Bureau 2019, p. 16). As for most of the other female inmates who were incarcerated in ‘Prisons other than Woman Jails’, their general occupancy rate sits at 73.7% (National Crime Records Bureau 2019, p. xiii). However, just as is the case in Woman Jails, there are significant prison overcrowding issues in particular states/union territories. For example: (1) (2) (3) (4) (5) (6)

Chhattisgarh [Occupancy rate of female inmates: 186.0%]; Uttarakhand [Occupancy rate of female inmates: 141.5%]; Uttar Pradesh [Occupancy rate of female inmates: 125.4%] West Bengal [Occupancy rate of female inmates: 120.7%]; Goa [Occupancy rate of female inmates: 120.0%]; and Jharkhand [Occupancy rate of female inmates: 99.4%] (National Crime Records Bureau 2019, p. 17).

It is interesting to note that while inmate capacity in Woman Jails increased by 21.7% from 2011 to 2016, the actual number of women prisoners during this same timeframe merely increased by 2.1% (National Crime Records Bureau 2019, p. 18). This stands in stark contrast with the female inmate capacity in ‘Prisons other than Woman Jails’ during that same period. Here, an increase of 10.6% of female prisoner capacity was met with a female inmate increase of 18.6% (National Crime Records Bureau 2019, p. 18). Thus, according to the National Crime Records Bureau (2019):

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[t]he occupancy rate in woman jail has decreased from 71.6% in 2011 to 60.1% at national level in 2016 (as on 31st December), whereas the occupancy rate of woman inmates in other jails has increased from 68.7% in 2011 to 73.7% in 2016 (p. 19)

Given that Woman Jails may have more staff and management equipped with the requisite expertise to address the special needs of women inmates, as well as, potentially being in a better emotional and cognitive position to empathise with their female prisoner counterparts, these surprising trends should be scrutinized more deeply, particularly as they relate to inmate mental health and prospects of rehabilitation. Unlike male inmates, woman prisoners are permitted, in certain circumstances [see the Supreme Court of India case of R.D. Upadhyay vs. State of Andhra Pradesh & Ors (2006)], to care for their minor children (usually under the age of six) while incarcerated. Thus, as at 31 December 2016, the National Crime Records Bureau notes that “… [t]here were 1649 women prisoners with 1942 children…. [and] [a]mong these woman prisoners, 400 women prisoners (with 459 children) were convicts while 1192 women prisoners (with 1409 children) were undertrial inmates [i.e. ‘a person who is currently on trial in a court of law’ (2019, p. 37)]” (2019, p. xv). The caring of minor children under the age of six in such spartan prison surroundings can potentially impose even more emotional stress on the mothers. That said, it could also be argued that having their children with them may alleviate some of the anxiety and guilt that these mothers would have experienced as a result of leaving their offspring in the care of others outside of prison (Harner and Riley 2013).

Mentally Ill Inmates Within the Indian Correctional Health System (as at 31 December 2016) Unfortunately, not much is disclosed by the National Crime Records Bureau about India’s mentally ill prisoners. So, for example, there is no definition of what encompasses mental illness within the context of the Indian correctional health system. This, of course, can be easily remedied by explicitly relying upon the diagnostic and treatment schemas of the American Psychiatric Association’s ‘Diagnostic and Statistical Manual of Mental Disorders, 5th Edition’ (or DSM-V), and the World Health Organization’s ‘International Statistical Classification of Diseases and Related Health Problems, 11th Edition’ (ICD-11). In essence though, a mental illness is a ‘clinically diagnosable disorder that significantly interferes with an individual’s cognitive, emotional or social abilities…’ and would include a whole range of short- or longterm anxiety, affective (or mood), and substance-use disorders (ABS 2008, p. 4). Given this lack of definitional parameters, it is not surprising that the relevant prison reports do not also describe the specific types of mental illness (including the incidence of co-morbidity) suffered by the inmates, whether affective or mood-related in nature; anxiety-related; and/or substance use-related—these three broad categories being examples of some of the more commonly presented mental illnesses (ABS 2008, pp. 91–96). There is likewise no breakdown in terms of the number of female

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and male mentally ill inmates, although figures are provided in relation to the number of mentally ill prisoners based on the state/union territories in which they are incarcerated in, as well as, their statuses as Convicts, Undertrials and Detenues (i.e. “any person held lawfully in custody” (National Crime Records Bureau 2019, p. 37), etc. (National Crime Records Bureau 2019, p. 175 & 182). What is additionally revealed is also this: “[a] total of 6013 inmates were reported as mentally ill out of [sic] total 433,003 inmates lodged in various jails in the country as on 31 December, 2016, accounting for 1.4% of total such inmates” (National Crime Records Bureau 2019, p. 175). This relatively low incidence of 1.4% in 2016 is consistent with figures from previous years: 1.2% in 2015 (National Crime Records Bureau 2016, p. 31); 1.3% in 2014 (National Crime Records Bureau 2015, p. 31); 1.2% in 2013 (National Crime Records Bureau 2014, p. 31); and 1.2% in 2012 (National Crime Records Bureau 2013, p. 31). Such low rates, however, are concerning because they are at variance with similar statistics from a range of other local as well as international studies. As Francis and Chong (2015) had previously noted, critically examining, analysing and formulating “possible strategies that can be applied in practice to address mental health issues (including substance abuse and illicit drug addiction) within the criminal justice system [is]…. certainly not a sterile exercise given how pervasive mental illness plagues the prison populations in India” (p. 90). This position was supported by a number of local Indian studies including: Goyal et al. (2011) and Kumar and Daria (2013). In fact, Ayirolimeethal et al. (2014) also highlighted this apparent variance by pointing out that ‘[m]ost of the Indian jails show a high occupancy rate and 0.9% of the total inmates were reported to be mentally ill…. [but] [a] study by Goyal et al. observed 28.8% psychiatric morbidity among convict prisoners’ (p. 151). There was therefore ‘… a need for further exploration of the mental health problems in prisoners” (Ayirolimeethal et al. 2014, p. 151). In their study involving 255 prisoners (both male and female), Ayirolimeethal and colleagues (2014) discovered that 175 or 68.8% of the examined cohort suffered from some form of mental illness, for example, substance use disorder (47.1%), antisocial personality disorder (19.2%), adjustment disorder (13.7%), mood disorder (4.3%) and psychosis (6.3%). This led them to conclude that: [m]ental health problems among prisoners were quite high…. The increased rate of psychiatric disorders should be a concern for mental health professionals and the policy makers (Ayirolimeethal et al. 2014, p. 150)

Chong and Fellows (2014) similarly contended that ‘the prevalence of such mental illnesses among convicted criminals within the community [was] extremely high’ (p. 188). In comparable studies conducted in other countries, for example, the Australian Bureau of Statistics [ABS] (2008), it was observed that: [o]f the 385,100 people who reported they had ever been incarcerated, 41% had a 12-month mental disorder, which is more than twice the prevalence of people who reported they had never been incarcerated (19%). People who reported they had ever been incarcerated experienced almost five times the prevalence of 12-month Substance Use disorders (23% compared with 4.7%), more than three times the prevalence of 12-month Affective disorders

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(19% compared with 5.9%), and almost twice the prevalence of 12-month Anxiety disorders (28% compared with 14.1%)” (p. 15).

These ABS results were likewise consistent with other Australian studies (Mullen et al. 2003; Ogloff et al. 2006) as well as those conducted in New Zealand (Brinded et al. 2001), Canada (Ogloff 1996), Ireland (Duffy et al. 2006), the United Kingdom (Howard and Christophersen 2003) and the USA (O’Keefe and Schnell 2007). Thus, it would be prudent not to simply cite the reported low incidence rates of mental illness among Indian prison inmates, and as Ayirolimeethal et al. (2014) suggested, there is ‘… a need for further exploration of the mental health problems in prisoners’ (p. 151).

Mental Illness and Its Impact on Prisoner Rehabilitation As previously stated, a mental illness is a ‘clinically diagnosable disorder that significantly interferes with an individual’s cognitive, emotional or social abilities…’ (ABS 2008, p. 4). Consequently, it is no surprise that Rule 62 of the United Nations ‘Standard Minimum Rules for the Treatment of Prisoners’ (1955) explicitly mandates that prisons should endeavour to provide medical services to detect and treat ‘mental illnesses or defects which may hamper a prisoner’s rehabilitation’. This link between mental illness or defects, and an inmate’s cognitive, affective and social capacities to successfully undergo rehabilitation programs, is almost axiomatic. Failure to rehabilitate inevitably leads to recidivism or re-offending post-release, and as Ayirolimeethal et al. (2014) pointed out, ‘[m]entally ill prisoners were… at risk of repeated incarceration’ (p. 150). A similar conclusion was reached by Baillargeon et al. (2009) as their findings suggested ‘… a substantially heightened risk of recidivism among released inmates with mental illness’ (p. 105). In fact, according to the literature review conducted by Anestis and Carbonell (2014), not only do ‘[o]ffenders with mental illness reoffend at higher rates’, they also reoffend ‘more quickly after incarceration than offenders without mental illness’ (p. 1105). Furthermore, being incarcerated in ‘total institutions’ like prisons or secure mental health facilities is an emotionally horrifying experience for many. Given that it is an austere environment fraught with danger and where inmates are constantly surveilled, disciplined and controlled (Foucault 1991, pp. 231–256), these severe situational and social conditions could lead to mental trauma or may exacerbate pre-existing mental illnesses or defects in inmates (WHO 1999). Kumar and Daria (2013) likewise highlighted the deleterious nature of such ‘total institutions’, and observed that ‘[p]risons are detrimental to mental-health’ (p. 369). The World Health Organisation (WHO) had also argued this very point, showing persuasively that the ‘deprivation of freedom is intrinsically bad for mental health, and that imprisonment has the potential to cause significant mental harm’ (1999, p. 4). Consequently, promoting effective mental health practices and programmes within prisons were strongly recommended as these could, among other objectives, increase the inmates’ capacity to address

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their criminal conduct, as well as, improve their chances of rehabilitation (WHO 1999, p. 9).

Gender as a Mediating Factor While the link between mental illness and an inmate’s capacity for rehabilitation is relatively well established, what may be less persuasive is the argument that gender is an important mediating factor between these two elements. Women and men are, after all, both members of the same Homo Sapiens species. However, there is increasing evidence and studies to show that there are indeed significant gender differentials in the presentation of symptoms, assessment, diagnosis and treatment of mentally ill prisoners. Even in community-based studies, Malhotra and Shah (2015, p. 206) showed that ‘[g]ender is a critical determinant of mental health and mental illness’, and as a result of this, ‘[t]he patterns of psychological distress and psychiatric disorder among women are different from those seen among men’. Although the analysis did not focus on studies that examined prison cohorts specifically or even of offenders, more generally, their community-based findings are nevertheless illuminating, and may be amenable to cautious extrapolation. Thus, it would appear that: (1) Women are more prone to internalizing disorders [for example, ‘depression, anxiety, and unspecified psychological distress’], while men are more susceptible to externalizing disorders [for example, ‘addictions, substance use disorders and psychopathic personality disorders’] (Malhotra and Shah 2015, p. 206); (2) Women are not only more prone to falling into depression than men, this mental disorder is also more persistent in the former, rather than the latter (Malhotra and Shah 2015, p. 206); (3) When depressed, women are more likely than men to present atypical or ‘reverse vegetative’ symptoms, for example, having a greater appetite for food, and as a consequence, experience weight gain (Malhotra and Shah 2015, p. 206), which may then negatively impact upon their health more generally, as well as their self-image; (4) Women suffer more serious symptoms than men when suffering from anxiety disorders (Malhotra and Shah 2015, p. 206); (5) While there is no significant gender difference in the rates of serious mental disorders such as schizophrenia and bipolar disorder, there are, however, femalemale variances in the ‘… age of onset of symptoms, clinical features, frequency of psychotic symptoms, course, social adjustment, and long-term outcome of severe mental disorders’ (Malhotra and Shah 2015, p. 207); (6) In contrast with men, women are more susceptible to using alcohol or other drugs as a response to some emotionally painful or stressful incident ‘… and women who abuse alcohol or drugs are more likely to have been sexually or physically abused than other women’ (Malhotra and Shah 2015, p. 207);

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(7) There are more women than men who attempt to commit suicide but there are more men than women who actually die from suicide. This latter rate, however, is significantly reversed in China, and to a lesser extent in India (Malhotra and Shah 2015, p. 207); and (8) Women experience cognitive, affective and behavioural changes during different phases of their menstrual cycle, and sometimes during the third trimester of their pregnancy and/or during the postpartum period (Malhotra and Shah 2015, p. 207). These variances, according to Malhotra and Shah (2015, p. 208), are potentially attributed to a range of toxic social factors (for example, misogynistic community values, patriarchal domination within the economic sphere, permissive norms concerning physical and sexual violence against women by men, etc.) as well as gender-specific features (for example, the female reproductive cycle, etc.). Consequently, women’s mental health should not be ‘considered in isolation from social, political, and economic issues’ (Malhotra and Shah 2015, p. 209) that may converge with female biological conditions to create a cognitively and emotionally intolerable psycho-social environment where the onset of mental illness is either hastened, or where a pre-existing mental illness is exacerbated. Other more relevant international studies (i.e. those based on prisoner cohorts) typically show similar gender differentials. For example, James and Glaze (2006) noted that women prisoners in the USA suffered higher rates of mental illness (i.e. mania, major depressive disorder, psychosis and substance abuse) than male prisoners across all three levels of prisons: (1) ‘State prisons: 73% of females and 55% of males; (2) Federal prisons: 61% of females and 44% of males; [and] (3) [L]ocal jails: 75% of females and 63% of males’ (p. 1). In another large study, this time conducted in the United Kingdom, Tyler et al. (2019) found that: [f]emales were significantly more likely than males to screen positive for personality disorder; particularly avoidant, dependent, masochistic, schizotypal, borderline, and paranoid personality types. Females were also significantly more likely than males to screen positive for somatoform, mood disorders, PTSD [Post-Traumatic Stress Disorder], psychotic disorders, eating disorders, and risk of suicidal behaviour (p. 1149).

Drapalski et al. (2009) discovered that ‘alcohol-related problems were twice as prevalent among male inmates’ (p. 203) as opposed to their female counterparts, although both genders reported similarly high rates of drug-related issues (p. 203). Drapalski et al. (2009) also observed that: (1) Women prisoners presented higher rates of symptoms for ‘somatic [or bodily] concerns, anxiety and other anxiety-related disorders than male prisoners’ (p. 201); (2) Women prisoners presented slightly higher rates of symptoms for traumarelated and borderline personality disorders although such symptoms were also commonly presented by the male prisoners (p. 203); and

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(3) There were also significant differences in seeking for, as well as, enrolling in, mental health treatment programs between the genders. By way of illustration, female prisoners were more likely to seek treatment than male prisoners even for substance abuse problems [women: 51%; men: 28%] (p. 203). Unsurprisingly, female prisoners were also more likely to enrol in appropriate treatment programs in jail than male prisoners (p. 204). While the above statistics appear to depict an objective picture in relation to the mental health variances between female and male prisoners, studies conducted by Dr Jenny Yourstone from Uppsala University would, however, advise some caution. This is because Yourstone and colleagues argued that—much, though not all—of the abovementioned type of statistics are actually underpinned by psychiatric diagnoses that could potentially be gender biased. In a Swedish study conducted by Yourstone et al. (2008) involving 45 practicing forensic psychiatric clinicians, 46 chief judges and 80 psychology students, they examined these participants’ forensic psychiatric assessments of vignettes that described a homicide committed by either a female or male offender who may or may not have been legally insane at the time of the crime. In this regard, gender bias refers to ‘[s]tereotypic beliefs about the characteristics that distinguish men and women’,… [f]or example, a general assumption in most cultures is that men are significantly more aggressive than women, whereas women often are characterized by passive and communal traits’ (Yourstone et al. 2008, p. 273). Their findings were strongly indicative that gender did indeed play an influential role in their decision as to whether the offender was, or was not, legally insane at the time of the offence. To that end, the: (1) Forensic psychiatric clinicians were more likely to conclude that the perpetrator was legally insane if the offender was female rather than male; (2) Psychology students were also more likely to conclude that the perpetrator was legally insane if the offender was female rather than male; but the (3) Chief Judges were more likely to conclude that the perpetrator was legally insane if the offender was of the same gender as themselves (Yourstone et al. 2008, p. 273). In a subsequent study, Yourstone et al. (2009) examined Swedish data on 4396 offenders who received court-ordered forensic psychiatric in-patient evaluations in order to uncover any gender variances in relation to their ‘psychiatric morbidity, offence classification, and legal insanity designation’ (p. 177). Yourstone and colleagues (2009) found that: (1) Female offenders were more likely to be diagnosed with a personality disorder than male offenders (p. 172); (2) Male offenders were more likely to be diagnosed with alcohol and/or drug dependence or sexual disorders than female offenders (p. 172); (3) Violent female offenders were more likely to be designated as legally insane as compared to male offenders (p. 177); and

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(4) Female offenders who were designated as legally insane were also more likely than men to likewise be diagnosed with a personality disorder even though this mental illness is not normally linked to legal insanity (p. 177). According to these researchers: [o]ne possible interpretation of the present findings is that there actually is a gender bias in forensic evaluations, that is, in clinical-legal practice in Sweden, the threshold for legal insanity is lower for female defendants than for men. It is noteworthy that evidence for gender bias has indeed been found within the broader range of general psychiatry… (Yourstone et al. 2009, p. 177).

Why Is There a Need for a More Gender-Responsive Approach? Covington and Bloom (2007) observed that ‘[a]s the number of women under correctional supervision continues to increase, there is an emerging awareness that women offenders present different issues than their male counterparts’ (p. 9). Consequently, there is, therefore, a need for a variegated gender approach, and as the preceding sections of this chapter have shown, this need is particularly required in the area of penal mental health. To understand how to accomplish this, and to ensure that such gender-oriented issues are analysed appropriately within a critical framework, feminist criminological scholars, Covington and Bloom (2007) proposed the use of one of ‘four fundamental theories for creating women’s services’, and they include: (1) (2) (3) (4)

Pathways Theory; Relational Theory; Trauma Theory; and Addiction Theory (p. 15).

To this end, the authors of this chapter have selected Trauma Theory as being the most appropriate paradigm in which to situate these complex mental health gender variations identified earlier. Trauma theory, according to Covington and Bloom (2007), defines trauma as ‘… both an event and a particular response to an overwhelming event’ (p. 17). This ‘overwhelming event’ or events could involve a range of harrowing situations or predicaments, for example, being: (1) (2) (3) (4) (5)

In an abusive family; A victim of intimate partner violence; Physically abused; Sexually abused; Subject to serious childhood maltreatment (Covington and Bloom 2007, p. 17), and so on.

For many girls and women who have been subject to such trauma, their response may take many forms. Covington and Bloom (2007) explained that:

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[t]he response is one of overwhelming fear, helplessness, or horror…. Women [may also] have different responses to violence and abuse. Some may respond without trauma, due to coping skills that may be effective for a specific event. Sometimes, however, trauma has occurred but may not be recognized immediately, because the violent event may have been perceived by the individual as normal (p. 17).

Sadly, victims often suffer from PTSD following such an ‘overwhelming event’, and Covington and Bloom (2007) lamented that: [f]requently, women have their first encounters with the justice system as juveniles who have run away from home to escape situations involving violence and sexual or physical abuse. Prostitution, property crime, and drug use can then become a way of life (p. 17).

According to Drapalski et al. (2009), PTSD symptoms were also very prevalent among the female inmates in their study, and relying upon the work of Lewis (2006), suggested that this could be attributed ‘… to the fact that many incarcerated women have been victims of prior physical and/or sexual abuse’ (p. 202). From an Indian context, Trauma Theory, is an ideal paradigm in which to better understand the nature of these mental health gender variances. Foreshadowed earlier, the study conducted by Malhotra and Shah (2015) is especially illustrative of this point. These scholars had already shown that women were suffering higher rates of depression, anxiety and somatic complaints compared to men (Malhotra and Shah 2015, p. 206). However, looking deeper into the recesses of this disparity, Malhotra and Shah attempted to identify the reasons for these differences. To that end, while acknowledging that hormonal changes women undergo during different phases of their reproductive cycle may increase their susceptibility to depression, Malhotra and Shah (2015) also argued that: [a]nother answer may be that the factors independently associated with the risk for CMD [Common Mental Disorders] are factors indicative of gender disadvantage. These factors include excessive partner alcohol use, sexual, and physical violence by the husband, being widowed or separated, having low autonomy in decision making, and having low levels of support from one’s family (p. 206).

Furthermore, Malhotra and Shah (2015) contended that: … stressful life events are closely associated with the occurrence of depression in vulnerable individuals. During their lifetimes, females are faced with various life stressors including childbirth and maternal roles, caring and nurturing the old and sick of the family. In addition, women are less empowered due to lesser opportunities of education and respectable employment. Moreover, even those who are financially secure fear to cross social lines and therefore too are apparently vulnerable (pp. 206–207)

While it may be argued that these additional factors pertaining to ‘… having low autonomy in decision making, and having low levels of support from one’s family’ or ‘… caring and nurturing the old and sick of the family…. [being] less empowered due to lesser opportunities of education and respectable employment…’ do not fall within the description of Trauma Theory outlined by Covington and Bloom (2007), the authors of this present chapter, however, contend otherwise. This is because the violence spoken of in Trauma Theory must be understood to be much more than just

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physical and sexual in nature. Galtung (1969) expanded our understanding in this regard by introducing the concept of ‘structural violence’. Galtung (1969) made it amply clear that: … when one husband beats his wife there is a clear case of personal violence, but when one million husbands keep one million wives in ignorance, there is structural violence. Correspondingly, in a society where life expectancy is twice as high in the upper as in the lower classes, violence is exercised even if there are no concrete actors one can point to directly attacking others, as when one person kills another (p. 171).

Sinha et al. (2017) noted that from an Indian perspective, structural violence took the form of Indian women facing ‘…the challenges of outdated and repressive governance structure, an inefficient legal justice system, a weak rule of law, and sociopolitical structures that are heavily male centric’. Consequently, these scholars argued that: [s]tructural violence impacts all aspects of women’s lives, their health, safety and that of their children and also society as a whole. The women are denied of their fundamental rights. … [H]er mental health is ruined by their patriarchal structure, … (Sinha et al. 2017).

Conclusion: The Way Forward According to Trauma Theory, for service delivery to be effective—in this case, the enforcement of the previously mentioned Rule 62 that requires ‘[t]he medical services of the institution… to detect and… treat any… mental illnesses or defects which may hamper a prisoner’s rehabilitation’—they must become, at the very least, ‘trauma informed’ (Covington and Bloom 2007, p. 17). This is because ‘[t]he standard operating practices (searches, seclusion, and restraint) [of prisons] may traumatize/retraumatize women’ (Covington and Bloom 2007, p. 17). Relying on the work conducted by Harris and Fallot (2001), Covington and Bloom (2007) outlined the key features of being ‘trauma informed’, and these include: (1) ‘[Taking] the trauma into account; (2) [Avoiding] triggering trauma reactions and/or retraumatizing the individual; (3) [Adjusting] the behaviour of counsellors, other staff, and the organization to support the individual’s coping capacity; and (4) [Allowing] survivors to manage their trauma symptoms successfully so that they are able to access, retain, and benefit from these services’ (p. 17). These are, in essence, the basic or fundamental steps that should be taken by Indian prison administrators and correctional mental health professionals if they want to become more gender-responsive to the mental health needs of their inmates. As for other measures, these can be divided into two main sections, the first being initiatives implemented at the prison or institutional level (for example, penal service delivery should be ‘trauma informed’); and the second being initiatives implemented at a socio-structural level (for example, improving female children’s access to education). Given that the second set of measures are outside the scope of this book chapter, the

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following recommended measures will be restricted to those that can be implemented at the prison or institutional level: (1) It would appear that based on the relevant data from the National Crime Records Bureau (2019, p. 18), Woman Jails are significantly underutilised given that its general occupancy rate decreased from 71.6% in 2011 to 60.1% in 2016 (although certain sites did experience overcrowding). This troubling trend should be examined closely given that such institutions are ideally positioned to address more effectively the gender-specific mental health needs of female inmates. (2) Tyler et al. (2019) suggested that ‘a more comprehensive, in-depth, and gender focused primary mental health [standardized screening tool]’ be employed at the initial incarceration reception stage to better detect, for example, ‘eating disorders, suicidal risk and PTSD for female prisoners’ (p. 1151). (3) Drapalski, Youman, Stuewig and Tangney (2009) made a number of suggestions, including: (a) Assessing the ‘differing needs of substance abusing men and women flexibly’ given that male inmates were twice as susceptible to alcohol-related problems than the female inmates (p. 203); and (b) Developing a deeper understanding of why male inmates were not ‘seeking jailbased substance abuse treatment’ at the same rate as similarly-suffering female inmates (pp. 203–204). (4) Yourstone et al. (2009) recommended the following two-stage approach: (a) Conduct additional studies to determine whether there is indeed ‘gender bias in forensic evaluations’ in other jurisdictions; and if so (b) To develop psychiatric evaluation tools that will be more ‘insensitive to any such bias’ (p. 177). (5) Cabeldue et al. (2019) advocated that female inmates be specifically screened for any history of victimization during the admission stage so that they can be identified ‘for effective treatment [of trauma-related mental illnesses] during incarceration’ (p. 67). It is envisaged that these gender-responsive measures—if properly implemented by prison administrators and correctional health professionals—will yield tremendous benefits to both female and male mentally ill inmates. Thus, by increasing the likelihood of being able to successfully detect and treat their mental illnesses or disorders, the prospect of their rehabilitation likewise improves, and with that, comes the greater likelihood of reduced levels of recidivism or re-offending post-release. That said, the above initiatives do relatively little to reduce the structural violence that women in India generally suffer from (Sinha et al. 2017), and while this cannot be examined in the detail it merits here, such an issue must surely be interrogated further in other more appropriate forums and platforms. There must be ‘bigger social change’, and as Malhotra and Shah (2015) argued, ‘[e]ducation, training, and interventions targeting the social and physical environment are crucial for addressing women’s mental health’ (p. 209). Dominus illuminatio mea et salus mea.

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References Anestis, J. C., & Carbonell, J. L. (2014). Stopping the revolving door: effectiveness of mental health court in reducing recidivism by mentally ill offenders. Psychiatric Services, 65, 1105–1112. ASC Division of Critical Criminology and Social Justice. (n.d.). About. Retrieved from https://div isiononcriticalcriminology.com/about/. Australian Bureau of Statistics (ABS). (2008). National survey of mental health and wellbeing: Summary of results, 2007. Canberra, ACT: ABS. Ayirolimeethal, A., Ragesh, G., Ramanujam, J. M., & George, B. (2014). Psychiatric morbidity among prisoners. Indian Journal of Psychiatry, 56, 150–153. Baillargeon, J., Binswanger, I. A., Penn, J. V., Williams, B. A., & Murray, O. J. (2009). Psychiatric disorders and repeat incarcerations: the revolving prison door. American Journal of Psychiatry, 166, 103–109. Brinded, P. M., Simpson, A. I., Laidlaw, T. M., Fairley, N., & Malcolm, F. (2001). Prevalence of psychiatric disorders in New Zealand prisons: a national study. Australian and New Zealand Journal of Psychiatry, 35, 166–173. Cabeldue, M., Blackburn, A., & Mullings, J. L. (2019). Mental health among incarcerated women: an examination of factors impacting depression and PTSD symptomology. Women & Criminal Justice, 29(1), 52–72. Cherukuri, S., Britton, D. M., & Subramaniam, M. (2009). Between life and death: women in an Indian state prison. Feminist Criminology, 4, 252–274. Chong, M. D., & Fellows, J. D. (2014). Crime and mental health: Implications for social work practice. In A. P. Francis (Ed.), Social work in mental health: Contexts and theories for practice (pp. 182–204). New Delhi: SAGE Publication. Covington, S. S., & Bloom, B. E. (2007). Gender responsive treatment and services in correctional settings. Women & Therapy, 29(3–4), 9–33. Drapalski, A. L., Youman, K., Stuewig, J., & Tangney, J. (2009). Gender differences in jail inmates’ symptoms of mental illness, treatment history and treatment seeking. Criminal Behaviour & Mental Health, 19, 193–206. Duffy, D., Linehan, S., & Kennedy, H. (2006). Psychiatric morbidity in the male sentenced Irish prisons population. Irish Journal of Psychological Medicine, 23, 54–62. Foucault, M. (1991). Discipline and punish: The birth of the prison. New York, NY: Vintage Books. Francis, A., & Chong, M. D. (2015). Application of strengths-based principles in addressing mental health issues in the criminal justice system. In A. Francis, P. L. Rosa, L. Sankaran, & S. P. Rajeev (Eds.), Social work practice in mental health: Cross-cultural perspectives (pp. 90–102). New Delhi, India: Allied Publishers. Galtung, J. (1969). Violence, peace and peace research. Journal of Peace Research, 6(3), 167–191. Goyal, S. K., Singh, P., Gargi, P. D., Goyal, S., & Garg, A. (2011). Psychiatric morbidity in prisoners. Indian Journal of Psychiatry, 53, 253–257. Harner, H. M., & Riley, S. (2013). Factors contributing to poor physical health in incarcerated women. Journal of Health Care for the Poor and Underserved, 24(2), 788–801. Harris, M., & Fallot, R. D. (2001). Using trauma theory to design service systems. San Francisco, CA: Jossey-Bass. Howard, D., & Christophersen, O. (2003). Statistics of mentally disordered offenders 2002, Cat. No. 1403. London: Offending and Criminal Justice Group, Research Development and Statistics Directorate, Home Office. James, D. J., & Glaze, L. E. (2006). Bureau of justice statistics special report: Mental health problems of prison and jail inmates. Washington, DC: U.S. Department of Justice. Kumar, V., & Daria, U. (2013). Psychiatric morbidity in prisoners. Indian Journal of Psychiatry, 55 (4), 366–370. Lewis, C. (2006). Treating incarcerated women: gender matters. Psychiatric Clinics of North America, 29, 773–789.

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Malhotra, S., & Shah, R. (2015). Women and mental health in India: an overview. Indian Journal of Psychiatry, 57(Supplement 2), 205–211. Mullen, P. E., Holmquist, C. L., & Ogloff, J. R. P. (2003). National forensic mental health scoping study. Canberra, ACT: Department of Health and Ageing. National Crime Records Bureau. (2013). Prison statistics in India 2012. New Delhi, India: Ministry of Home Affairs, Government of India. National Crime Records Bureau. (2014). Prison statistics in India 2013. New Delhi, India: Ministry of Home Affairs, Government of India. National Crime Records Bureau. (2015). Prison statistics in India 2014. New Delhi, India: Ministry of Home Affairs, Government of India. National Crime Records Bureau. (2016). Prison statistics in India 2015. New Delhi, India: Ministry of Home Affairs, Government of India. National Crime Records Bureau. (2019). Prison statistics in India 2016. New Delhi, India: Ministry of Home Affairs, Government of India. Ogloff, J. R. P. (1996). The Surrey pretrial mental health program: Community component evaluation. Coquitlam, BC: British Columbia Forensic Psychiatric Services Commission. Ogloff, J. R. P., Davis, M. R., Rivers, G., & Ross, S. (2006). The identification of mental disorders in the criminal justice system. Canberra, ACT: Criminology Research Council. O’Keefe, M. L., & Schnell, M. J. (2007). Offenders with mental illness in the correctional system. Journal of Offender Rehabilitation, 45, 1–2. R. D. Upadhyay Vs. State of Andhra Pradesh & Ors. (2006). AIR 2006 SC 1946. Sinha, P., Gupta, U., Singh, J., & Srivastava, A. (2017). Structural violence on women: an impediment to women empowerment. Indian Journal of Community Medicine, 42(3), 134–137. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5561688/. Tyler, N., Miles, H. L., Karadag, B., & Rogers, G. (2019). An updated picture of the mental health needs of male and female prisoners in the UK: Prevalence, comorbidity, and gender differences. Social Psychiatry and Psychiatric Epidemiology, 54, 1143–1152. White, R., & Perrone, S. (2015). Crime, criminality and criminal justice (2nd ed.). South Melbourne, VIC: Oxford University Press. World Health Organization (WHO). (1999, November). Mental health promotion in prisons. Report presented at the WHO Meeting, The Hague, Netherlands. Yourstone, J., Lindholm, T., Grann, M., & Fezel, S. (2009). Gender differences in diagnoses of mentally disorder offenders. International Journal of Forensic Mental Health, 8(3), 172–177. Yourstone, J., Lindholm, T., Grann, M., & Svenson, O. (2008). Evidence of gender bias in legal insanity evaluations: a case vignette study of clinicians, judges, and students. Nordic Journal of Psychiatry, 62, 273–278.

Chapter 15

Gender and Community Mental Health: Experiences of Mehac Foundation—A Community-Based Mental Health Service in Kerala, South India Anupama V. Prabhu, Anu Sonia Vincent, Uma Parameswaran, and Chitra Venkateswaran

Gender bias and discrimination are social barriers that greatly influence the identification, treatment and rehabilitation of the mentally ill. Studies on the category of gender have underscored how stereotyped perceptions and expectations force thinking, action and behaviour of women and men on the basis of the dominant social and cultural structures of a society and the way in which it is organized, and not only on the basis of biological differences (Doyal 1998). Thus, belonging to a particular gender is expected to shape a person’s life choices and options, build one’s self-image and decisively influence the way a person perceives the world and his/her social relationships. This is an all-encompassing sociocultural narrative. Striking influences and illustrations of this narrative are pandemic in the field of mental health, especially in terms of access to treatment resources. These gender differences are one of the most researched areas in modern psychiatry, and it has yielded stable and significant results through many studies. A large quantum of these studies emphasize that recognizing the aetiology and epidemiology of mental illness regardless of gender or other social constraints and acknowledging their differences are indeed essential for the purposive advancement of universal mental health care.

Gender and Mental Health Consistent with the gender splits, dominant conceptions of femininity came to associate women with personal characteristics of nurturance, sensitivity and emotional expressiveness. In contrast, dominant conceptions of masculinity associated men A. V. Prabhu · A. S. Vincent · U. Parameswaran · C. Venkateswaran (B) Mehac Foundation, Kochi, India e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2020 M. Anand (ed.), Gender and Mental Health, https://doi.org/10.1007/978-981-15-5393-6_15

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with characteristics of assertiveness, competitiveness and independence (Connell 1995; Flax 1993; Rosenfield et al. 2005). Taking all psychological disorders together, studies show that there are no differences overall in men and women’s rates of psychopathology. It is therefore clear that neither gender is worse off than the other in mental health in a comprehensive sense. However, there are gender differences in particular types of psychiatric disorders. Women experience higher rates of depression and anxiety disorders than men, whereas men show higher rates of substance abuse and antisocial behaviour and are at risk of suicide than women (Kessler et al. 2003). Women exceed men in internalizing problems of anxiety and depression, in which problematic feelings are turned inwards against the self. Women experience a great loss of energy, motivation and interest in life more often than men. They more frequently feel that life is hopeless, coupled with a deep sense of helplessness to improve their circumstances. They more often have trouble concentrating as well as with sleeping and appetite, which can be too much or too little. Depression occurs twice as often in women as in men and is considered to be the second leading cause of global disease burden by 2020 (Murray et al. 1996). Most of the women do the bulk of childcare and housework even if they work hours comparable to their husbands outside home and bring in the same income (Greenstein 2000; Hochschild and Machung 1989; Lennon and Rosenfield 1994; Pleck 1985). These responsibilities for the household work often result in an overload of demands that raises women’s levels of depressive and anxious symptoms (Bird and Rieker 1999; Krause and Markides 1985; Lennon and Rosenfield 1992; Ross and Mirowsky 1995; Rosenfield 1989, 1992). When household tasks are split, women tend to do the kinds of tasks over which there is less discretion and that must be repeated often, such as preparing meals, shopping, cleaning and laundry. Women have a consistently higher rate of suicide attempts, while men have a higher rate of completed suicide. Gender-based violence is significant predictor of suicidality in women. Girls from nuclear families and women married at a very young age are at a higher risk for attempted suicide and self-harm. Low attendance in hospital settings is partly explained by the lack of availability of resources for women. Women are at increased risk of violence and physical abuse. Populationbased studies suggested that between 25 and 50% of women around the world report being victims of physical abuse at some point in their lives (Heise et al. 1994). Violence towards women is related to high rates of depression and co-morbidities, especially suicidality in them. In contrast, men more frequently exhibit externalizing problems of substance abuse and antisocial behaviour, which are more destructive and problematic to others. Greater substance abuse means that men more often consume excessive amounts of alcohol and other drugs—in both quantity and frequency—than women. They more often experience extreme physical consequences from substances, such as blackouts or hallucinations. Drugs or alcohol interferes with their lives more often, causing problems at work or school or in the family. Men are more likely to be dependent on a substance, needing to use more and more to get the same effect, and to have serious psychological or physical consequences from attempts to stop. Greater

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antisocial behaviour includes disruptive disorders in childhood and adolescence— such as attention deficit/hyperactivity disorder, conduct disorder and oppositional defiant disorder—as well as antisocial personality disorder in adulthood. This means that, beginning at an early age, males are more often aggressive or antisocial in a wide range of areas, including violence towards people and animals, the destruction of property, lying and stealing. Partly as a result, males more often have problems forming close, enduring relationships (APA 2013). Schizophrenia is another chronic disorder with the lifetime risk around 1% for both men and women. Differences can be found in the age of onset of symptoms with men typically having an earlier onset of 4–6 years than women (Piccinelli et al. 1997). Women as compared to men do seek help and disclose mental health problems to others. On the contrary, men are more likely to report problems with alcohol use while women mostly seek help for emotional problems (Allen et al. 1998). There is also a lack of research in gender differences in children and how it affects their general mental health, which would reflect in morbidity in later life. Most research focuses on women facing violence, abuse, depression and other issues, while only a few studies focus on men. In sum, neither men nor women exceed the other in mental health problems, but rather experience very different kinds of problems.

Mental Health in India and Kerala The recent National Mental Health Survey conducted across 12 states (including Kerala) showed that common mental disorders are a huge unrecognized burden and contributed for nearly 90% of total morbidity among 18+ adults. Severe mental disorders comprising schizophrenia, non-affective psychosis and bipolar affective disorders ranged from 0.4 to 2.5% across states. Substance use disorders, especially among young adults to the extent of 22.4% in all the 12 surveyed states, highlight the seriousness of problem (Murthy 2017). Burden of mental disorders among genders is almost equal. Common mental disorders like depression and anxiety affect women to a greater extent, a finding consistent with other studies. Severe mental disorders were identified more among men. Despite the slow progress made in mental healthcare delivery across the country, the study revealed the huge treatment gap for all types of mental health problems ranging from 74 to 90% for all mental disorders and 81–86% for common mental disorders and substance use disorders, respectively. These disorders are equally important and need long-term care and rehabilitation along with stigma removal and community integration. India is home to nearly 104 million elderly citizens. The fact that nearly 10.9% are in need of mental health care signifies the problem and need for elderly mental health programmes. According to the 2011 Census, Kerala has an estimated population of 3.34 crores. The male and female populations are 47.98 and 52.02%, respectively, and

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have the highest sex ratio, 1084 women per 1000 men. Kerala has a significant elderly group, with 12.55% of total population falling in the age group of 60 years and above. Kerala has around 10.2% prevalence, and commonly used drugs were found to be Cannabis, Dextropropoxyphene, Nitrazepam and Alprazolam. Survey also sheds light on the increasing high suicidal risk in India. India’s contribution to global suicide deaths increased from 25.3 in 1990 to 36.6% in 2016 among women, and from 18.7 to 24.3% among men. India’s proportional contribution to global suicide deaths is high and increasing. SDR in India is higher than expected for its socio-demographic index level, especially for women, with substantial variations in the magnitude and men-towomen ratio between the states. Married women account for the highest proportion of suicide deaths among women in India. Recently, high suicide deaths in adolescent girls have gained attention, with suicides having surpassed maternal mortality as the leading cause of death globally (Dandona et al. 2018). This has implications for a state like Kerala which has one of the highest prevalence of suicidal risk (12.6%).

What Can Be Done? It is therefore amply clear that mental health cannot be considered in isolation from social, political and economic issues. Lessening gender disparities is essential to introduce gender-sensitive services in mental health treatment. Community mental health services must be tailored to include people from all strata and provide equal access to treatment services. Such services need to adopt a life course approach that acknowledge current and past gender-specific exposure to stressors and also respond sensitively to ongoing gender-based responsibilities. There is a need to educate people regarding the options and services available under such services, and also it must gain the confidence of people by providing privacy and confidentiality. Addressing gender disparities in mental health requires actions at many levels. National policies must be adopted considering gender disparities in risk and outcome. India at present lacks a structured care pathway to address its mental health concerns; an effective framework must be developed to improve mental healthcare practice and policy. There are various specific ventures in India at present addressing mental health concerns, and one such organization is Mehac Foundation, Kerala, which focuses on providing long-term mental health care in the community particularly to such sections in the community that lack access to comprehensive care. This model emerged from the strong and significant palliative care movement in North Kerala; these initiatives in palliative care, involving people, indicate the efficacy of the community model. The movement initiated to focus on people with cancer at the start subsequently grew to encompass people with many chronic diseases. It was regarded both as a challenge and as a meaningful opportunity to incorporate the principles of palliative care for mental health care. Mehac Foundation has adapted this approach. This movement has actually enabled the community to own healthcare programmes, take responsibilities in policies and don an active role in the expansion of the programme (Venkateswaran et al. 2014). This socially relevant

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movement has an important impact on numerous components of mental health and illness experience in the community including stigma, perception of mental health and illness, gender, social roles and responsibility. Globally, this concept is evolving and a working definition of palliative psychiatry has been proposed as a starting point for discussing of the usefulness of palliative psychiatry as a new approach (Trachsel et al. 2016).

Mehac Foundation—Experiences in the Community Mehac Foundation seeks to provide comprehensive psychosocial care to the needy, particularly to such sections of society who do not have access to health resources in general and particularly to monetary resources. Mehac model involves empowering local communities to impart free mental health services to fellow human beings under the guidance and supervision of trained medical professionals. The organization pursues the objective by initiating, facilitating and strengthening the mental health component of existing general and primary healthcare services. The focus is on providing free and quality care to the needy through a network comprising a variety of local institutions and individuals to function as effective mental healthcare coordinators. The following goals were kept in mind while planning and implementing the present model: • The programme in the community implemented with local partners who take the responsibility of developing and sustaining the service. A stepped long-term care approach with layers of care and intervention with volunteers, local team of nurses, doctors and other healthcare workers, social workers and psychiatrists at the different steps ensuring monitoring, surveillance and continuity of care. • Planning intervention in accordance with need of person and in accordance with the community where he belongs. • Regular treatment through ‘home visits’ once in every month by psychiatrists, social worker, psychologist and volunteers as a team and separately with particular focus on those who have poor access and availability, who are bedridden and vulnerable and those who have end of life issues. • Psychoeducation for the family members and relatives. • Creating awareness in neighbours, engaging them to help the ill person to get rehabilitated and thereby increasing their psychosocial support. • As part of psychosocial rehabilitation engaging patients in supervised activities like helping in nearby farms, shops, engaging them in self-help groups. • Availability of medications free of cost to ensure compliance to treatment. The NGO partners with 19 clinics including destitute homes, out of which this model has been incorporated in 17 clinics. In the last 9 years, the feedback and response to this model have been as follows:

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Approach

Palliative Care

Symptoms

Traditional

symptom control

Treating symptoms

foster acceptance

Focus on cure

coping strategies Focus of care

Integration

of

psychological, social, and spiritual aspects

curing the disease predominance

of

biomedical aspects of illness

Responsibilities

Death

Multidisciplinary team

physician / patient

including volunteers

as main decision-

approach

makers

developing a culture of discussion

impending suicide prolonging life

neutral attitude towards death

Fig. 15.1 Concept of the model

• Appropriate timely interventions resulting in better and faster symptom resolution. Focus is not on the traditional model of care but on a long-term care model (Fig. 15.1). • Ease of accessibility to treatment, resulting in hope, trust and faith in the treatment process. • Breaking the shroud of shame and fear of isolation associated with the illness. • Active involvement of local volunteers in care and follow-up process. • Open communication systems between the volunteers, treating team and affected families that reduce prejudice between majority and minority group members as stated by ‘contact hypothesis’ (Allport 1954). • Restoration of community functioning and well-being of an individual.

Mental Health Activities Carried Out by Mehac Foundation As pointed out earlier, researchers and clinician have become more interested in addressing the gender differences in mental health for several reasons. A prominent reason among them is that the study of gender differences has evolved as one of the

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stable findings in psychiatry and hence it is anticipated that enhanced research would yield more interesting results in the aetiology of illness. In addition, focusing on gender provides understanding of the differences. This would help make psychosocial interventions more effective. • Gender-Sensitive Services Mehac provides easily accessible and affordable services equally to both males and females. On an average, this NGO provides services to 753 females and 621 males on regular follow-ups. Mehac team visits beneficiaries at their homes on a either weekly or monthly basis. These home visits are done in collaboration with palliative care nurses and ASHA workers of the primary healthcare team. Health services for women tend to focus on their reproductive functions, neglecting the needs of women outside the reproductive ages. In many developing countries, women complain about lack of privacy, confidentiality and information about options and services available (Vlassoff 1999). Awareness is a major step to resolve the present scenario. Mehac Foundation has initiated several programmes to increase awareness particularly among women in association with the National Health Mission of Ernakulam District. Some of these awareness programmes were delivered to ASHA volunteers, Kudumbashree members, Anganwadi workers and mothers of Anganwadi children on mental health, illness, post-partum illness and childhood disorders. Awareness sessions have been provided to around 4000 women directly by professionals and to around 10,000 women indirectly by empowering the health volunteers. • Gender and Volunteering in the Community Volunteering plays a major role in community-based services, which bridges the gap between the society and health professional. On a community level, it is essential to associate with local organizations, network of existing volunteers and local government bodies to ensure sustainability. Volunteers play a pivotal role in providing social support. Mehac focuses on empowering volunteers as a priority whereby to help them grow as advocates of mental health. Even though not many studies have been done in the gender differences related to volunteering, one study has found that women volunteer more than men. This variance matters because it helps to understand and improve the quality of work being done. This also helps in evolving appropriate strategies, including for fieldwork. There are various reasons why women are more into volunteering than men. One of the main reasons found was that women feel more reinforced in doing work for others than men. ASHA workers are an inevitable component in providing primary health care to the village level. Along with other services, they also help in creating and enhancing awareness on health and its social determinants. They are able to connect well to women and children as they are themselves wives and mothers and belong to the same community. The work of ASHA workers has empowered a lot of women, and many of them are joining similar groups to serve the community. Mehac has trained many of them through a number of awareness and training classes. The activities

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and interventions of Mehac work are carried out by trained professionals, where again women outnumber men; around 70% of community-based professionals and 80–85% of volunteers are women. • Support for Older People in the Community Ageing parents of individual with severe mental illness are the hidden population in the mental health field. Caregiving regularly falls primarily on the parents if the family is having a child with mental illness. Parents grow as the child grows and their difficulties too. The services are often called upon to provide long-term care for their disabled child. It becomes too difficult at the time when most other ageing parents look forward to their adult child to take care of them. The issues become more complicated when the family does not have an earning member, or when it is a single mother or when they do not have access to health services. In addition to this, symptoms get exacerbated due to lack of compliance, forgetting to provide medication to son/daughter, which in turn increases the hardship of the aged parent. Mehac had initiated a project with the Grandmother Eva Foundation to provide pension to selected single ageing mothers with mental illness. An amount is provided to them every month for purchasing monthly ration. Other than this, regular home care is being provided for all the patients, especially for those who cannot have access to services. Medications and psychosocial support would be provided to family, especially to single parents which helped to lessen the relapse rate and the burden of caretaker. • Homelessness and Mental Illness Homelessness and mental illness collectively aggravate socio-economic and sociocultural problems to such massive scale pushing people with illness into a vicious cycle. Our experience shows both genders suffer in this continuous and debilitating process marked by illness exacerbation, wandering, admissions in longterm care homes, lack of information of family and home, challenges in motivating the family to take them back and repeatedly ‘returning to the street’ with no support. Many factors like poor income/income-generating opportunities, ownership of land and houses with related legal issues, stigma against marriage of people with mental illness, social acceptance for remarriage of spouses of mentally ill women, drug compliance issues and stigma as a whole make women more vulnerable to homelessness. There are gender differences in the acceptance and owing of the responsibility of aftercare by the families. Women are more likely to experience rejection, stigmatization, denial of care and poor access to appropriate healthcare facilities. The impact of mental illness also holds gender bias. Women are required to be the primary carers if their husbands are mentally ill; it was their own families that were responsible for women’s care if they were to become ill. This scenario often leads to homelessness (Moorkath et al. 2018). Home-based care and initiation of rehabilitation efforts in the community either by empowering the family members or the community as whole to take responsibility to provide comprehensive care to homeless people are seen to be one of the most significant interventions. Currently, lack of guidelines is a major gap in our settings.

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The efforts of Mehac in the community focus on empowering families and providing continuous support to them enable home-based care. There is a constant emphasis on educating families to keep persons with illness in their homes and support their reintegration. The network of volunteers and health systems in the community are supported in this regard by Mehac team, as mental illness and follow-up are still perceived separate to other chronic diseases in the community. • Home Again Programme Reintegration of person with mental illness into the society is the ultimate aim of every psychiatric intervention. However, in some cases it becomes difficult even when they are symptomatically stable. It becomes difficult when people with mental illness are homeless; scenario worsens if it is a woman. People then would have to stay at residential homes even when they are stable. Mehac Foundation is a local institutional care partner on the project, ‘Home Again: shared housing with supportive services for homeless people with mental illness experiencing long-term care needs’ supported by funding from Grand Challenges Canada to The Banyan. The Banyan, registered in 1993, is not for profit organization offering comprehensive mental healthcare services for persons living in a state of homelessness and/or poverty. Over the last two decades, The Banyan’s services have reached out to over 10,000 individuals, currently operate out of 13 service access points in Tamil Nadu, Kerala, Maharashtra and Assam, and service a population of over 8 lakh individuals overall. Home Again, one of The Banyan’s flagship programmes, involves the creation of choice-based, inclusive living spaces through clustered or scattered homes in rural or urban neighbourhoods with a range of supportive services for people with persistent mental health issues living for extended periods of time in institutional care settings. Along with housing, the innovation features allied supportive services including social care support and facilitation (opportunities for a diverse range of work, facilitation of government welfare entitlements, problem-solving, socialization support, leisure and recreation), access to health care, case management (detailed bio-psychosocial assessments and personalized care plans) and onsite personal assistance.

Social Enterprise—Day Care Centre A social enterprise offering a space for engagement and to help people improve their skills, overcome difficulties of long-term illness and focus on income-generating methods has been initiated in Alappuzha district in Kerala. It aims to help and support people who still find it hard to manage with everyday life or to mingle with people. The activities in the rehabilitation centres are aimed to develop self-esteem and improve

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cognitive skills, social skills and communications. This programme has been taken up more by the female beneficiaries in our services. It is our observation that women are more willing to come to rehabilitation centres than men. Stigma may be one of the reasons that lead to this gender difference. Hence, the rehabilitation services are structured accordingly. A sewing unit has been set up specifically for women with severe mental illness and who are co-operative. This venture is not only meant for the occupational rehabilitation and income generation but also as a social enterprise. The aim is also to provide an inclusive space in the community for social identity and engagement. Mehac usually helps the males to start small units or shops near their home with the same goal. One of the social outcomes of our programmes is the increasing number of marriages of people who remain under Mehac care. These marriages usually take place after discussion with the team and understanding the implications of illness and treatment. The presence of the team in the community enables the families to take decisions moving beyond the stigma. Case Vignette 1 A 39-year-old male, diagnosed with schizophrenia, living with his old mother, his illness was continuous and of 20 years duration. The mother was very old and was not able to take care of him without others help, but no one helped them because he was very aggressive and abusive towards outsiders. She used to give him medicines using a very old prescription when he becomes symptomatic. She was physically and economically not well to take him to hospital. On the first day of home care, he argued with the team and went out from home. He went to a drainage pond and started bathing using soap. He had wandering behaviours, going around asking for money to smoke, and he snatches money if anyone denies him. Medication was started, and mother was educated about illness and importance of regular medications. After one month of regular home care, his selfcare was improved. During second home care, his mother said that ‘After long years she and her son slept on the mat peacefully, earlier he used to become aggressive at night and never allows her to sleep, making noises’. He started going to nearby farms and started earning after the home care. He becomes symptomatic occasionally but is manageable. This is to highlight that how in the community the gender difference is not very apparent, and women take the role of carer despite ageing and make efforts to meet ends. The family as a whole is isolated, and the secondary behaviours which accompany a male with chronic illness especially substance use are very significant.

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Case Vignette 2 Ms RD 51-year-old single mother, from a low socio-economic status, was found living in a very small thatched shelter outside her own home for 15 years, without getting out it and without letting other to come near her. The complaints reported by her sister were irritability, decreased talk, poor self-care, decreased appetite, muttering to self, irrelevant speech, withdrawal. She was diagnosed as having chronic psychosis. She was taken care by her old mother who was paranoid herself who did not allow anyone to take her to hospital. Mother used to get monetary gain from other people who sympathized at the situation. She was neglected by her family and neighbours due to stigma attached to mental illness that it will not be cured and because they felt that she would become aggressive if they go to her. She was identified in a state of neglect, and even her children were hesitant to care for her. Her husband was no longer with her. Mehac was taken to her by the community medical team over there. Even though her mother was hostile, her sister was made to understand about the need of medications and regular follow-ups. Follow-up was done on weekly basis, and compliance was ensured. Care was provided by multidisciplinary approach, and she started recovering just after 3 months of treatment. The neighbours were provided information regarding illness and their role in helping her and were assigned to include her in some social activities. After 6 months of treatment, she started going for ‘Thozilurappu’ (Mahatma Gandhi National Rural Employment Guarantee Act). After 1 year and 6 months of continuous care, she has started a dance school and started teaching dance for 15 students. She occasionally becomes symptomatic; then she is admitted to a residential home where Mehac does weekly clinics. Once the symptoms resolve, she is taken back home. Her family is quite supportive presently. This narrative highlights the neglect a woman has to endure chronic illness, abandonment and neglect being a common consequence. This also indicates how empowerment is possible in the community, irrespective of genders.

Conclusion Our experience indicates that community-based programmes with participation of people in the community and local volunteers are one of feasible models with multidimensional positive results. The community-based programmes not only provide clinical models but more importantly address the social components, which are often the most challenging factors hindering complete care for people with mental illnesses in the community irrespective of gender. Demonstration of such programmes should lead to change in policy and approach of mental health within the districts and at the

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national level. From Mehac’s perspective, challenges in sustainability indicate need for strong partnership model and that would facilitate generation of evidence, which in turn can play a role in influencing policies and service models. • ASHA worker An Accredited Social Health Activist (ASHA) is a woman selected by the community, who is trained and deployed to function in her own village to improve the health status of the community. They are instituted by the Government of India’s Ministry of Health and Family Welfare (MoHFW) as a part of the National Rural Health Mission (NRHM). ASHAs act as a link between the community and healthcare services and ensure that the primary healthcare services are accessed by the rural poor. The role of ASHAs has been extended to other fields like prevention and control of communicable diseases, identification and control of NCD’s, palliative care and community-based mental health programme (National Rural Health Mission, 2005). • Kudumbashree workers Kudumbashree is the poverty eradication and women empowerment programme implemented by the State Poverty Eradication Mission (SPEM) of the Government of Kerala. The name Kudumbashree in Malayalam language means ‘prosperity of the family’. Kudumbashree is essentially a community network that covers the entire state of Kerala. It is arguably one of the largest women’s networks in the world (“Kudumbashree | What is Kudumbashree” 2019).

References Allen, L. M., Nelson, C. J., Rouhbakhsh, P., Scifres, S. L., Greene, R. L., Kordinak, S. T., et al. (1998). Gender differences in factor structure of the self-administered Alcoholism screening test. Journal of clinical psychology, 54(4), 439–445. Allport, G. W. (1954). The nature of prejudice: (1979). Berkeley: Perseus Books Publishing LLC. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub. Bird, C. E., & Rieker, P. P. (1999). Gender matters: An integrated model for understanding men’s and women’s health. Social Science and Medicine, 48(6), 745–755. Connell, R. W. (1995). Masculinities. Cambridge/Sydney/Berkeley. Dandona, R., Kumar, G. A., Dhaliwal, R. S., Naghavi, M., Vos, T., Shukla, D. K., et al. (2018). Gender differentials and state variations in suicide deaths in India: The global burden of disease study 1990–2016. The Lancet Public Health, 3(10), e478–e489. Doyal, L. (1998). Gender and health: Technical paper. Geneva: World Health Organization. Flax, J. (1993). Multiples: On the contemporary politics of subjectivity. Human Studies, 16(1), 33–49. Greenstein, T. N. (2000). Economic dependence, gender, and the division of labor in the home: A replication and extension. Journal of Marriage and Family, 62(2), 322–335. Heise, L. L., Pitanguy, J., & Germain, A. (1994). Violence against women. The hidden health burden.

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Kessler, R. C., Barker, P. R., Colpe, L. J., Epstein, J. F., Gfroerer, J. C., Hiripi, E., et al. (2003). Screening for serious mental illness in the general population. Archives of General Psychiatry, 60(2), 184–189. Krause, N., & Markides, K. S. (1985). Employment and psychological well-being in Mexican American women. Journal of Health and Social behavior, 15–26. Kudumbashree | What is Kudumbashree. (2019). Retrieved from http://www.kudumbashree.org/ pages/171. Lennon, M. C., & Rosenfield, S. (1992). Women and mental health: The interaction of job and family conditions. Journal of Health and Social Behavior, 316–327. Lennon, M. C., & Rosenfield, S. (1994). Relative fairness and the division of housework: The importance of options. American Journal of Sociology, 100(2), 506–531. Machung, A. (1989). Talking career, thinking job: Gender differences in career and family expectations of Berkeley seniors. Feminist Studies, 15(1), 35–58. Moorkath, F., Vranda, M. N., & Naveenkumar, C. (2018). Lives without roots: Institutionalized homeless women with chronic mental illness. Indian Journal of Psychological Medicine, 40(5), 476. Murray, C. J., Lopez, A. D., & World Health Organization. (1996). The global burden of disease: A comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020: summary. Murthy, R. S. (2017). National mental health survey of India 2015–2016. Indian Journal of Psychiatry, 59(1), 21. National Rural Health Mission. (2005). Ministry of Health and Family Welfare, National Rural Health Mission, New Delhi. In Guidelines on accredited social health activists. New Delhi: Ministry of Health and Family Welfare, p. 11. Piccinelli, M., Gomez Homen, F., WHO Nations for Mental Health Initiative, & World Health Organization. (1997). Gender differences in the epidemiology of affective disorders and schizophrenia (No. WHO/MSA/NAM/97.1). Geneva: World Health Organization. Pleck, J. H. (1985). Working wives/working husbands. California: Sage Publications. Rosenfield, S. (1989). The effects of woman’s employment: Personal control and sex differences in mental health. Journal of Health and Social Behaviour, 77–91, March 1. Rosenfield, S. (1992). Factors contributing to the subjective quality of life of the chronic mentally ill. Journal of Health and Social Behavior, 299–315. Rosenfield, S., Lennon, M. C., & White, H. R. (2005). The self and mental health: Self-salience and the emergence of internalizing and externalizing problems. Journal of Health and Social Behavior, 46(4), 323–340. Ross, C. E., & Mirowsky, J. (1995). Does employment affect health? Journal of Health and Social Behavior, 230–243. Trachsel, M., Irwin, S. A., Biller-Andorno, N., Hoff, P., & Riese, F. (2016). Palliative psychiatry for severe persistent mental illness as a new approach to psychiatry? Definition, scope, benefits, and risks. BMC Psychiatry, 16(1), 260. Venkateswaran, C., Jose, S., & Francis, A. P. (2014). Community mental health and NGO engagement: The Kerala experience. In Social work in mental health: Areas of practice, challenges, and way forward, p. 276. Vlassoff, C. (1999). Gender inequalities in health in the third world: Uncharted ground. Social Science & Medicine, 39(9), 1249–1259. November 1.

Chapter 16

Practising Strength-Based Approach with Women Survivors of Domestic Violence Gunjan Chandhok and Meenu Anand

The strength-based practice (SBP) has gained lot of attention in the last decade. With belief in the client as the actor or agent of change, it concentrates on the inherent strengths of individuals, families, groups and organizations, deploying peoples’ personal strengths to aid their recovery and empowerment. Strength-based practices are empowering alternatives to traditional methods with individuals, group or organizational work as they allow people to identify and build on their strengths so that they can reach their goals, and retain or regain independence in their daily lives (Pulla and Francis 2015). Social Care Institute for Excellence (2015) explains SBP as ‘a collaborative process between the person supported by services and those supporting them, allowing them to work together to determine an outcome that draws on the person’s strengths and assets. As such, it concerns itself principally with the quality of the relationship that develops between those providing support and those being supported, as well as the elements that the person seeking support brings to the process. Working in a collaborative way, it promotes the opportunity for individuals to be co-producers of services and support rather than solely consumers of those services’. A strength-based approach is a philosophy for working with individuals, families, groups, organizations and communities (O’Neil 2005). It is an ecological perspective that recognizes the importance of people’s environments and the multiple contexts that influence their lives (Saint-Jacques et al. 2009). The perspective recognizes the resilience of individuals and focuses on the potentials, strengths, interests, abilities, knowledge and capacities of individuals, rather than their limits (Grant and Cadell 2009; Scerra 2011). The strength approach is a specific method of working with and resolving challenges experienced by the engaged person. It does not attempt to ignore the problems and difficulties. Rather, it attempts to identify the positive basis of the person’s resources (or what may need to be added) and strengths that will lay the basis G. Chandhok (B) · M. Anand Department of Social Work, University of Delhi, New Delhi, India e-mail: [email protected] © Springer Nature Singapore Pte Ltd. 2020 M. Anand (ed.), Gender and Mental Health, https://doi.org/10.1007/978-981-15-5393-6_16

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Fig. 16.1 Seven key principles of strength practice. Source Chapin (1995), Early and GlenMaye (2004), Kisthardt (1992), Miley et al. (2004), Poertner and Ronnau (1992), Rapp (1993), Saleebey (1992), Sullivan and Rapp (1994), Weick et al. (1989)

to address the challenges resulting from the problems. The strengths of a person give one a sense of how things might be and ideas about how to bring about the desired changes. The strength approach as a philosophy of practice draws one away from an emphasis on procedures, techniques and knowledge as the keys to change (Hammond and Zimmerman 2012). It offers a genuine basis for addressing the primary mandate of community and mental health services—people taking control of their own lives in meaningful and sustainable ways (Hammond 2010) (Fig. 16.1). The core of strengths based perspective lies in its humanistic roots that iterate the humans’ capacity to grow and change (Early and GlenMaye 2004; Pulla 2014). In addition, believing that people are capable of making their own choices and taking charge of their own lives promotes empowerment. It means that human beings have the potential to use their strengths and overcome adversity as well as to contribute to society (Cowger 1994). Pulla (2017) talks about asking three pertinent questions to the clients: ‘What has worked for you before? What does not work for you? And what might work in the present situation for you?’ There are altogether seven principles of the strength perspective (Chapin 1995; Early and GlenMaye 2004; Kisthardt 1992; Miley et al. 2004; Poertner and Ronnau 1992; Rapp 1993; Saleebey 1992; Sullivan and Rapp 1994; Weick et al. 1989), and these areas are as follows: 1. People have a number of strengths and have the capacity to continue to learn, grow and change. 2. The focus of intervention is on the strengths and aspirations of clients.

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The community or social environment is seen as being full of resources. The service provider collaborates with clients. Interventions are based on client self-determination. There is a commitment to empowerment. Problems are seen as the result of interactions between individuals, organizations or structures rather than deficits within individuals, organizations or structures (as cited in Pulla and Francis (2015) A Strengths Approach to Mental Health).

After gaining an understanding of SBP, the following attempts to draw its application with respect to working with survivors of domestic violence. An area that needs significant attention with respect to SBP-based interventions is violence against women.

The Vicious Cycle of Violence Against Women: International and National Scenario Violence against women is considered as a serious threat to human rights violation (Kumar 2012; Zuchowski 2014; WHO 2016). Domestic violence and mental health are inseparable components defining women’s mental and emotional health. Unfortunately, over several decades women have been soft targets for various heinous forms of violence owing to their poor socio-economic status in the society which may include but are not limited to coercive sexual abuse, dowry deaths, honour killings, sexual harassment at workplace, female infanticide, acid attack and physical harm by way of serious injuries inflicted by in-laws or intimate partner. Understanding various forms of violence against woman, it may be appropriate to categorize them into three broad domains, i.e. physical, sexual and psychological violence. Further, Sriram and Mukherjee (2001) explain that effects of violence also may be classified into emotional, social and psychopathological categories predominantly based on the range and intensity of violence. WHO (2005) affirms that domestic violence primarily assumes a single intent, i.e. to control over and to make the person feel inferior. Highlighting the social context of violence, Sriram and Mukherjee (2001) emphasized the lasting inequality as the social causative factors wherein the groups of people are termed as unequal on the basis of their sex, caste, class and religion. Consequentially, the dominant group presuming their supremacy labels the subordinate group as ‘inferior’ or ‘defective’. Therefore, the more dominant and powerful group with rigid institutional status and control becomes completely insensitive to the wants and desires of the less powerful group. The dominant group would rather resort to brute force over negotiation to achieve their goals of complete governance (Forte et al. 1996). The less powerful group is often compelled to exhibit submissive traits, and any potential or initiative to develop assertiveness may be grossly or subtlety curbed down by means of violence. The prevalence rate of violence against women ranges from 16 to 50% in their lifetime. The study also exclaimed that at least one in five women have been victims

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of rape or attempted rape during their lifetime (WHO 2013). The study on global and regional estimates of violence against women (2013) highlighted that globally nearly thirty-five percent (35.6%) of women have been victims of violence. About forty-two percent (42%) women, who have experienced physical or sexual abuse or both, have also acquired serious injuries as a result of violence. The study estimated that almost thirty-eight percent (38%) murders of women committed globally are reported to be committed by their intimate partners. Similarly, a Global Study on Homicide (United Nations Office on Drugs and Crime 2018) reported that out of the 87,000 women intentionally killed worldwide in 2017, an alarming 58 percent (50,000 women) were killed by their family members or intimate partners. This means that globally, 137 women were killed every day by a member of their own family. Focusing upon South East Asia region, the study showcased that lifetime prevalence of intimate partner violence (physical and/or sexual) or non-partner sexual violence or both of all women (above 15 years) in the region approximately stands at forty percent (40.2%). In the case of India, National Family and Health Survey-4 (NFHS-4) carried out during 2015–16 highlighted that one in three women (15–49 years) has faced domestic violence of various forms. Cases of domestic violence where women reported physical abuse stood at 29 and 23% in rural and urban areas, respectively. Reflecting upon the statistics of ever-married women who have ever experienced spousal violence then, NFHS-4 data highlights that about twenty-nine percent (28.8%) of ever-married women (15–49 years) have experienced spousal violence. Furthermore, the National Crime Records Bureau (2016) data reflects an alarming 55.2 crime rate for total crime against women. The NCRB report exclaimed that the ‘majority of cases under crimes against women were reported under ‘Cruelty by Husband or His Relatives’ (32.6%) followed by ‘Assault on Women with Intent to Outrage her Modesty’ (25.0%), ‘Kidnapping & Abduction of Women’ (19.0%) and ‘Rape’ (11.5%)’. There is indeed an inextricable link between the impact of violence on women and their mental health. WHO (2013) highlighted that ‘gender determines the differential power and control men and women have over the socioeconomic determinants of their mental health and lives, their social position, status and treatment in society and their susceptibility and exposure to specific mental health risks’. Recognizing gender as a crucial determinant of mental health and mental illness, it is essential to note that ‘gender’ assumes a key position in manifesting a woman’s susceptibility to both violence and mental health. Understanding the intrinsic relationship between gender, violence and mental health, violence may be regarded as the major reason for harm and injury against women and the most typical cause of depression among women (Zuchoswki 2014). Elucidating various factors, WHO (2013) reiterated that ‘Depression, anxiety, somatic symptoms and high rates of co-morbidity are significantly related to interconnected and co-occurrent risk factors such as gender-based roles, stressors and negative life experiences and events. Gender specific risk factors for common mental disorders that disproportionately affect women include gender-based violence, socioeconomic disadvantage, low income and income inequality, low or subordinate social

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status and rank and unremitting responsibility for the care of others. The high prevalence of sexual violence to which women are exposed and the correspondingly high rate of Post-Traumatic Stress Disorder (PTSD) following such violence, renders women the largest single group of people affected by this disorder’. WHO (2013) also highlighted that ‘Violence related mental health problems are poorly identified. Women are mostly reluctant to disclose a history of violent victimization unless physicians ask about it directly’. Consequentially, the magnitude of violence becomes complicated as a result of expensive and high rates of utilization of the health and mental healthcare system. Advancing cohesive linkage between violence against women and mental health through prominent women’s mental health facts (WHO 2013): • Depression is not only the most common women’s mental health problem but may be more persistent in women than men. • Depressive disorders account for close to 41.9% of the disability from neuropsychiatric disorders among women compared to 29.3% among men. • Leading mental health problems of the older adults are depression, organic brain syndromes and dementias. A majority are women. • Unipolar depression, predicted to be the second leading cause of global disability burden by 2020, is twice as common in women. • Gender differences occur particularly in the rates of common mental disorders— depression, anxiety and somatic complaints. These disorders, in which women predominate, affect approximately 1 in 3 people in the community and constitute a serious public health problem. Furthermore, NMHS (2015–16) provides evidence for the prevalence of significant gender differentials that exist with regard to different mental disorders. The overall prevalence of mental morbidity is higher among males (13.9%) than among females (7.5%). However, specific mental disorders like mood disorders (depression, neurotic disorders, phobic anxiety disorders, agoraphobia, generalized anxiety disorders) and obsessive compulsive disorders is higher in females. Considering these facts, it is evident that gender disparities exist in the mental health arena calling for deeper insights. Let us now understand the key associations between violence and mental health through a gendered lens.

Assimilating Cycle of Violence Against Women Through Field Narratives Undoubtedly, the cost of domestic violence is humongous which mainly includes lifelong emotional distress and mental health issues. Kumar (2012) elucidates that psychological health effects as experienced by the survivors are far more precarious than physical health effects. Depression, anxiety, post-traumatic stress disorder, insomnia, alcohol and drug dependence, amplified suicidal and homicidal thoughts,

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eating disorder, poor reproductive and sexual health as well as a range of somatic and psychological complaints are some of the significant mental health problems experienced by women who were abused (Sagar and Hans 2018; Zuchowski 2014; Kumar 2012). The following section presents field-based narratives based upon qualitative research conducted by the first author. The research undertaken by the first author was a conscious attempt to identify several linkages between spousal violence and its influence on woman’s overall health and well-being. In-depth interviews were carried out using interview schedule. Twelve young married women aged 18–35 years having at least one up to four children residing in the urban slums of Delhi were interviewed. The qualitative study was directed towards understanding the role of sociocultural factors in influencing the health-seeking behaviour of women in the backdrop of challenges imposed by urbanization. Let us now understand the interlinkages between violence and mental health through a perspective of a domestic violence survivor. Reena (name changed) is a 35-year-old married woman having three daughters and a son residing in a one-room rented house in West Delhi’s unauthorized colony. Reena has been married for more than fifteen years now and was the only steady earning (used to work as domestic helper) person of her family till she developed serious injuries followed by symptoms of depression. Her eldest daughter, 14 years old, has left her studies and taken the responsibility of her family by working as a domestic helper in those houses where her mother used to work earlier. Reena’s daughter shares that her mother’s marital life has been full of challenges with continuous bashing and threats from her father’s side. Reena’s husband is a man addicted to alcohol, often forces himself on her and beats her till she is in an unconscious state. Reena’s daughter narrates: My mother has never experienced any happy moment in her married life. She has only witnessed constant verbal and physical abuse. My father is an alcohol addict for the past twelve years. Every day he returns back in the drunk state and beats my mother till she is in an unconscious state. He has no apprehensions from his children and neighborhood for his abusive behavior. My mother would often try to convince my father to leave his addiction for the sake of our better future. However, such conversation would only lead to more battering. At present, my mother is undergoing treatment and I have left my studies to earn a living. My mother suddenly starts screaming while sleeping in the night requesting my father not to beat her. Sometimes during early hours in the morning, she is seen slapping herself and blaming herself that she is not a ‘good woman’. For the rest of the day, she keeps herself busy by cooking good food and doing other household chores just to please my father. When I will grow up, I will not marry anyone because I don’t want to get physically abused by any man.

She explains that her mother often requests his father to leave his addiction for the sake of his children which only leads to more mauling. Reena was seen with several marks of old bruises and injuries with some few fresh wounds on her face and stomach. Besides physical injuries, it is important here to consider the serious harm done to Reena’s self-confidence as an unfortunate outcome of constant battery and violent treatment. Reena is undergoing treatment in the nearby government hospital

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not only for her physical injuries but also for the symptoms leading her closer to mental illness. Elaborating upon Reena and her daughter’s experience, it can be analysed that such incidents of violence do affect not only the woman but also her entire family. Jeevitha and Suman (2010) drew attention towards the unfortunate blight of domestic violence as family violence which leads to several psychological problems in the victim causing a decline in her overall well-being and functioning. These consequences also influence the caregivers triggering frequent conflicts and neglect in the family. The absence of maternal inputs and marital tension weakens familial bonds straining family cohesion, resilience and happiness. Various studies (Banyard et al. 2008; Suman 2011) explain that childhood family violence contributes to poor mental well-being in the adulthood and greater susceptibility to trauma. Impact of childhood exposure to violence is vast and far-reaching as such children are prone to develop deviant behaviours and most likely to perpetrate intimate partner violence in their adult relationships because they have learnt this behaviour from their fathers as something being very normal and casual in a marital bond (Suman 2011; LaViolette and Barnett 2014; Promundo and UN Women 2017). Thus, the cycle of violence continues exposing young children, adolescents and women to diverse problems hampering their interpersonal relations (Suman 2011). Key associations have also been found between alcohol use, violence and psychological distress too. The research findings of various studies (Ponnudurai et al. 2001; Fals-Stewart 2003; Flake and Forste 2006; Michel and Suman 2009) suggest that women married to an alcohol addict are most likely to be assaulted physically, emotionally, sexually and financially which may be seen as the most critical factors leading to range of mental health issues. Another case illustration elucidates the central associations between violence and low self-esteem. ‘Anita’ (name changed) is a 22-year-old married woman and a mother of a one-year-old boy. Anita stays with her husband in a rented one-room set. Anita mostly stays at home to take care of her son and other household chores but exclaims that she is a working woman too though she works from home. She takes orders from the factory and makes ribbons to be inserted in mobile chargers. Despite Anita’s multitasking abilities, her husband always underestimates her. Her husband is habitual of quitting his job every second day rendering them with no savings. Anita is no exception when it comes to violent abuse. Anita explains the fact that she has a steady source of income and is the sole bread earner of the family and this does not go well with her husband’s male ego. To establish his supremacy as the head of the family or more crudely as the only ‘male member’ of the family, her husband often resorts to brutal sexual behaviour. Anita shared that her husband did not even spare her during her pregnancy days, and soon after the delivery when her episiotomy stitches were still fresh, her husband sexually forced himself on her and her stitches came off causing heavy blood loss and intense pain On the third day of delivery, my husband forced me for sexual intercourse and my episiotomy stitches broke off. I was in so much pain that I could not even breathe properly. The damage done to the stitches cannot be repaired because of which I am always vulnerable to acquire serious infections. My husband now finds me no more attractive. My husband has no steady

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job and often gets annoyed despite my steady source of income. In my opinion this is the only reason he sexually abuses me. But still I will continue to work and financially support my family because I have to secure my son’s future. I am ashamed of myself that I am not a good wife and unable to sexually satisfy my husband’s needs. I often doubt that my husband will leave me for some other woman, but I can’t say anything to him because being a man it’s his right.

The violent incident has caused her severe gynaecological complications as stitches could not be repaired later on making her vulnerable to severe forms of RTIs/STIs. Anita tells that after this incident, her husband often scolds her and passes cruel comments that she is no more attractive and is incapable to satisfy her husband’s sexual desires. Understanding from Anita’s perspective, it is evident that Anita has developed a sense of poor body image, blaming herself for being unworthy of marital bliss. She fears losing social position in the society if her husband abandons her and therefore approves of her man’s conjugal infidel intentions too. Acknowledging parallel resemblance, noted studies (WHO 2013; World’s Women 2015) suggested that approximately 70% of women globally have been victims of physical or/and sexual abuse from their intimate partner in their lifetime. Studies have highlighted that women who have been victims of violence have higher rates of depression, greater risk of gynaecological complications and heightened vulnerability to acquire HIV than women who have not experienced violence (Kumar et al. 2008; Suman 2011; WHO 2013; LaViolette and Barnett 2014; World’s Women 2015; Nayak 2016; Chandhok 2020). Kaushik (1988) explains family violence to be an individual or collective act of inflicting violence on a relative by blood or marriage, and a woman’s struggle against violence is a never-ending complex web percolating throughout her life. The aforementioned case illustrations of violence clearly signify that constant mauling and objectification of a woman by significant members of her family lead to the development of sense of guilt, shame and inadequacy to please her family members, thereby labelling herself as ‘dreadful’ and being worthy of such immoral maltreatment. Women’s low levels of self-esteem compel her to remain silent of her ordeals. The culture of silence surrounding violence has its own connotations, wherein the society (92%) despite believing that situations of domestic violence are detrimental for the physical and mental health (Kumar 2012) chooses to play upon the victim reinforcing the victim to remain silent and linger in the violent situation may be out of fear of ostracization (Sriram and Mukherjee 2001). Analysing the situation from the national-level NFHS (2015–2016), NCRB (2014) and Census (2011) data, an estimated ninety-nine percent (99.2%) of violence faced by women goes unreported with only 3.5% of victims seeking help from police (Bhattacharya 2018). However, it is important to note here that seeking help from police or any such legal institution does not mean that a case was registered against the perpetrator of violence. At this juncture, it will be prudent to explore various factors contributing towards this culture of silence. Reviewing the studies (Srinivasan 1987; Sriram and Mukherjee 2001; Gracia 2004; Kumar 2012; Davar and Ravindran 2015), women reported fear of isolation, rejection from the society, family and husband, shame and guilt, poor

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support system and financial dependence as some of the vital barriers in reporting the incidents of violence. Undeniably, the arising insecurity is a direct precursor of diminishing overall self-concept and self-esteem that may lead to social dysfunction. Impeding social withdrawal and isolation thus makes the victim more susceptible to depression and other psychopathological conditions (Forte et al. 1996; UNIFEM 1992; Sriram and Mukherjee 2001; Kumar 2012; Francis 2014). After understanding critical relationship between violence and mental health, it is now important to realize how patriarchal structure of dominance and subordination work in congruence to each other. A woman as a victim of violence who has been structurally taught to remain silent of her strategic and practical needs by default builds upon the capacity to be emotionally and physically vulnerable for her batterer. Contrary to this, Miller (1976) highlighted that a woman’s compassionate and contributing personality is actually her strength being highly ignored by the society including women themselves who consider these qualities as their key weakness. Similarly, Forte et al. (1996) acknowledge a woman’s capability to respond to other’s mood and communication as a defence strategy for survival. It is noteworthy that, even though both the shared experiences of women were a classic example of women’s subordination making them vulnerable to violence, they both showcased a relevant degree of determination to never lose hope and to continue putting in efforts in the anticipation of positive future one day. Anita on the one hand continues to financially support her family and takes pride that she is a working woman, and Reena on the other hand continues to diligently dedicate herself towards her reproductive roles. Therefore, it becomes imperative to acknowledge the efforts of survivors of violence and their family members (like Reena’s daughter) and channelize the positive energies, resources, hopes and desire to build upon the right attitude towards self and empower them. Let us now understand how strength approach can be effectively applied to empower survivors of domestic violence.

Embedding Strength-Based Practice in Working with Survivors of Domestic Violence Pulla and Francis (2014) explain the strength approach to mental health as ‘an endeavour to promote a culture of hope and enhance client’s autonomy and selfdetermination to the maximum degree possible’. Extending support in a positive conducive environment is the ultimate road to recovery. Saleeby (1992) is considered to be the chief architect of strength-based approach, focused towards accomplishing goals and appreciating potentials of the clients by dropping doubts and inhibitions through exploring client’s existing strengths and resources. Viewing violence against women and mental health issues from a sustainable development perspective, it can be affirmed that both present major impediments

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leading to violation of human rights by creating a complex muddle of gender inequality and social exclusion. Understanding the importance of strength-based perspective in social work practice, they work in conjunction with each other with a mutual endeavour to enhance coping mechanisms as purposeful agents and not mere functionaries (Pulla and Francis 2014). Social work practice, largely drawing from its core guiding principles of self-determination and respect for client’s inherent dignity and worth, strengthbased approach to social work practice honour the inherent wisdom of the human spirit. NASW (2016) emphasized that ‘social work’s strengths-based, person-in environment perspective provides the contextual focus necessary for client-centered and family-centered care and is unique among the health professions’. Application of strength-based approaches in mental health settings essentially focuses upon achieving goals and visions to facilitate better quality of life to clients by mobilizing client’s strength which include talents, knowledge, capacities and resources. Social work practice in mental health settings is one of the most wellknown arenas for professional practice which has throughout upheld the spirit of viewing a human body as an amalgamation of various physical, psychological, social and economic factors contrary to a mechanistic medical model. The bio-psychosocial model of health considers complex nature of human beings as a by-product of ‘nature’ and ‘nurture’. Every human being has a unique personality with unique experiences, thus representing holistic ecosystem. Strength-based perspective to social work practice by largely draws its inspiration from the ecosystem and ‘person in environment’ theories (Weick et al. 1989; Saleebey 1997; Pulla and Francis 2014; Wood 2015). The NASW standards for social work practice in healthcare settings (2016) through its guiding principles explain strength perspective that, ‘rather than focus on pathology, social workers elicit, support, and build on the resilience and potential for growth and development inherent in each individual’. The conventional notions of working on client’s weaknesses, dysfunctional issues and illness mainly require focus on removing client’s impediments focusing on client’s shortfalls than acknowledging their skills, capabilities and strengths. Strength perspective may be understood as a criticism and response to deficit-oriented psychotherapeutic model of social work practice (Saleebey 1992; Guo and Tsui 2010; Pulla 2012). The SBP does not turn a blind eye to the problems or pain that abused women experience, and it guides social workers to identify, build on and mobilize the women’s personal strengths. Wood (2015) links the SBP as a significant theoretical foundation in dealing with survivors of intimate partner violence. Black (2003) assessed the strength-based perspective as being interwoven with feminist and empowerment models and a common tool in working with partner violence survivors. Her study of domestic violence court advocates confirmed that they use a strength orientation to practise. According to Saleebey (2013), following comprehensive concepts may be applied to apply strength-based approach in dealing with clients: • Empowerment: It indicates the intent to and the processes of assisting clients to discover and expand the resources within and around them. It is assumed

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that the strengths of individuals and communities are renewable and expandable resources. Social workers trained in establishing rapport and effective communication through empathetic listening, by enabling catharsis, mirroring of feelings, honesty, warm relationship, can help the survivors of violence identify their major problems, rank their fears and deal with their feelings. Social workers working with SBP strongly believe that every person has strengths and abilities to cope with life challenges. They can help the women to explore probable alternatives, formulate a plan of action and take informed decisions (Saleebey 2013; Anand 2017) with an optimistic approach. Membership: Most people want to be responsible, recognized and valued members of a community. Without membership is to be in a dangerous position. The condition of alienation is tragically quite common for many individuals and groups, and due to this they are marginalized and oppressed on a daily basis. It is important to be aware of the fact all of us are entitled to the dignity, respect and responsibility that comes with such membership. Resilience: It is a fact that people do rebound from major dilemmas that individuals and communities do surmount and overcome serious and troubling adversity. It has been documented that particularly demanding and stressful experiences do not always lead to inevitability and vulnerability. WHO (2011) reiterates the need for building resilience that can be developed by enabling them to identify supports in their life, giving them practical suggestions for people to meet their own needs, asking about past coping strategies and affirming their ability to cope with their situation. Resilience can also be strengthened by motivating them to use positive coping strategies and avoid negative coping strategies. Healing and Wholeness: Healing implies both wholeness and innate resource of the body and mind to regenerate and resist when faced with disorder either physical or emotional. Of course, for proper healing to occur there is a need for beneficent relationship between individuals and their larger social and physical environment. Social workers can enable the battered women to develop a clear picture of own understanding of their situation by ‘listening’ to their experiences (Saleebey 2013; Anand 2017). Holland et al. (2014) suggest promoting change through motivational interviewing, perhaps acknowledging that many women will be experiencing the process of change or loss and struggle with denial or ambivalence (Messing et al. 2015). Dialogue and Collaboration: Dialogue implies empathy, identification with and inclusion of other people. Survivors can be enabled to think critically, be assertive to take back control over their lives, put the violence that they have been subjected to behind and think of future strategies to end future violence against them (Anand 2017). Collaboration requires being open with our clients and where both parties listen to each other and a mutuality of goals and means to achieve them are arrived at. Suspension of Disbelief: The worker needs to be open and listen to the clients without bias and avoids making value judgement. Clients’ belief systems based on their cultural norms and customs need to be respected.

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Conclusion Intimate partner violence can be considered as an immediate, harrowing and an overpowering incident causing radical alterations in the person’s environment. Undoubtedly, social workers have a role to play in helping women to recognize abuse. Once this recognition has taken place, work can begin to reconnect women to the resources, supports and opportunities needed to overcome coercive control (Stark 2013). Application of strength-based perspective in social work practice acknowledges the core intentions of mental health professionals, i.e. enhancing the coping mechanisms of any individual, community or a society as a whole. Strength-based perspective sustains client’s self-esteem and self-determination by focusing upon their resources and achievements accentuating better psychological and social adaptation. Sustainable Development Goals (2030) promoting mental health and well-being vigorously advocate for persistent professional engagement and creation of healthy support system to infuse organic transformations. Unconditional regard to the ‘power of resilience’ and ‘bouncing back’ (Pulla and Francis 2014) deems imperative towards creation of purposeful effective relationships with the clients resulting into magical transformations and healing. Paradigm shifting of positivist lens of objective epistemology towards holistic paradigms of bio-psychosocial models of health promotes affirmations of strengths, positive attitudes and self-concept. The pathway between recognizing destructive powers of violence against women to the realization of constructive power of resilience may seem to be an atypical and unusual belief. However, drawing similarities from Darwin’s theory of evolution which lay emphasis on an individual’s capacity to compete, survive and reproduce vitally implies to the psychological and emotional evolution as well. The human emotional and psychological anatomy is inherently wired to respond to physical and social challenges through constant internal self-discovery, awareness and exploration leading to evolution of human species. However, it is also important that we appreciate strengths, practise resilience and accumulate resources which our empowering in nature is strongly against the societal evils of gender inequalities and social exclusion. Hopes and aspirations, dreams and desire, optimism and zest for life master the recipe of our road to recovery and redefining self. Relevance of strength-based approaches to mental health and well-being with survivors of domestic violence entrusts social workers with an immensely essential responsibility of redefining meaning of life by sustaining valuable inner assets.

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